program coordinator manual - vumc
TRANSCRIPT
Program Coordinator Manual
Updated April 2020
Program Coordinator Manual 1
Table of Contents Welcome ................................................................................................................................................................................. 4
Resources ................................................................................................................................................................................ 4
Office of Graduate Medical Education.................................................................................................................................... 5
Who to Contact in GME ...................................................................................................................................................... 5
Duties of the Program Coordinator ........................................................................................................................................ 8
A Year in the Life of a Residency/Fellowship Program ........................................................................................................... 9
ERAS® - the Electronic Residency Application Service.......................................................................................................... 13
How Does ERAS® Work? ................................................................................................................................................... 13
Recruitment and Selection.................................................................................................................................................... 15
Interviewing Don’ts........................................................................................................................................................... 15
Required Documentation of Selection Process for All Applicants Considered................................................................. 16
International House Staff...................................................................................................................................................... 17
International Medical Graduates...................................................................................................................................... 17
Visas for International House Staff ................................................................................................................................... 17
The Match ............................................................................................................................................................................. 21
New Hires.............................................................................................................................................................................. 23
New Hire Payroll ............................................................................................................................................................... 23
Miscellaneous ....................................................................................................................................................................... 25
Annual Program Evaluation .............................................................................................................................................. 25
Call Rooms......................................................................................................................................................................... 25
Computer Systems Access ................................................................................................................................................ 25
House Staff Member Request to Review GME File …………………………………………………………………………………………………….. 25
House Staff Member Request to Review Program File ………………………………………………………………………………………………. 25
Moonlighting..................................................................................................................................................................... 25
Napping and Transportation Options for Post-Call Residents .......................................................................................... 25
NPI Numbers ..................................................................................................................................................................... 26
Pagers................................................................................................................................................................................ 26
Tennessee Medical License Exemption ............................................................................................................................ 27
V-Net Codes ...................................................................................................................................................................... 27
VUMC ID............................................................................................................................................................................. 27
Vacation ............................................................................................................................................................................ 27
Program Coordinator Manual 1
Kronos timekeeping for House Staff ................................................................................................................................. 27
White Coats....................................................................................................................................................................... 28
Program Coordinator Manual 2
Identification Badge/VUMC Badge Bucks............................................................................................................................. 29
Meal Money ...................................................................................................................................................................... 29
Liability Coverage for House Staff......................................................................................................................................... 30
New Resident and Fellow Orientations ................................................................................................................................ 31
New Innovations ................................................................................................................................................................... 32
Federal Funding, the Department of Finance and You: How Program Coordinators play a role in funding of GME........... 33
Advancement ........................................................................................................................................................................ 35
Reappointment Process .................................................................................................................................................... 35
Payroll Process for Advancing, Transferring and Terminating House Staff .......................................................................... 37
Visiting Residents/Fellows .................................................................................................................................................... 40
Contracts for Visiting Residents/Fellows .......................................................................................................................... 40
Meal Money for Visiting Residents/Fellows ..................................................................................................................... 41
Observerships/Externships ................................................................................................................................................... 41
Elective Away Rotations (Domestic and International) ........................................................................................................ 42
Exiting House Staff ................................................................................................................................................................ 43
Program Letters of Agreement (PLA).................................................................................................................................... 45
Contracts between Institutions ............................................................................................................................................ 46
Compliance Requirements for House Staff........................................................................................................................... 47
House Staff Manual............................................................................................................................................................... 48
Policies and Other Information Regarding House Staff .................................................................................................... 48
Internal Reviews.................................................................................................................................................................... 50
Special Reviews ................................................................................................................................................................. 51
Expansion and New Programs .............................................................................................................................................. 52
GME-Coordinated Meetings ................................................................................................................................................. 52
Forms/Documents and Online Tools .................................................................................................................................... 54
Accreditation Council for Graduate Medical Education (ACGME) ....................................................................................... 55
Overview and Organization of ACGME ............................................................................................................................. 55
Mission and Scope ............................................................................................................................................................ 55
Review Committees .......................................................................................................................................................... 55
ACGME Requirements ...................................................................................................................................................... 56
Institutional Requirements ............................................................................................................................................... 56
Common Program Requirements ..................................................................................................................................... 56
Specialty and Subspecialty Specific Program Requirements ............................................................................................ 57
Program Accreditation...................................................................................................................................................... 57
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Initial Accreditation........................................................................................................................................................... 57
Continued Accreditation ................................................................................................................................................... 58
Documentation/Forms for ACGME Programs .................................................................................................................. 61
ACGME Site Visit Preparation ........................................................................................................................................... 63
Quick Reference Web Links .................................................................................................................................................. 68
Quick Phone/Contact Guide ................................................................................................................................................. 70
Common Acronyms/Abbreviations Used in GME................................................................................................................. 72
Glossary of Terms.................................................................................................................................................................. 73
See Appendix I for VUMC GME Records Retention Worksheet for Programs………………………..…………………………………………85
Program Coordinator Manual 4
Welcome
The first edition of this manual was a collaborative effort between the GME office staff and the members of the Coordinators’ Manual Committee: Derenda Gold (Chair), Marsha Bailey, Michael Beasley, Birdia Byars, Judy King, Stephanie Burnham, Debby Scraggins, Julie Smith, and Betty Warner. We will continue to update and add information for the benefit of all Program Coordinators, and welcome your input. The GME office appreciates the support and contributions of everyone involved. Thank you!
Please note: When the term “resident” is used, most of the time it refers to all house staff. PC means Program Coordinator; PD means Program Director; AO means Administrative Officer.
Expert Tip: Searching this PDF In addition to navigating this PDF manual via the Table of Contents and in-text links, you can search the PDF for a word or phrase. With the manual open in your web browser, type Ctrl+F, then type your search word or phrase in the Find box that appears.
Resources
In addition to this reference manual, the following resources will be very helpful:
• The House Staff Manual covers a broad range of topics, many of which will be useful to you in writing
your own program’s policies and procedures manual. Topics include, but are not limited to: Conditions of Employment, Moonlighting, Supervision of Medical Students, Holiday/Vacation/Sick Time, Resident/Fellow Eligibility and Selection; Benefits; Support Services, GME Evaluation and Disciplinary Guidelines, and House Staff Complaint/Grievance Procedures. The manual is updated annually and updates can be accessed from the GME website. https://prd-medweb- cdn.s3.amazonaws.com/documents/gme/files/HS%20Manual%20-%20FINAL.pdf
• The GME Office website, especially the forms, tools, and instructions page.
https://www.vumc.org/gme
• The ACGME website, http://www.acgme.org
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Office of Graduate Medical Education
The Office of Graduate Medical Education (GME) is dedicated to support the human resource and administrative operations for GME programs and House Staff at Vanderbilt University Medical Center. GME operates under the direction of DIO Kyla Terhune and Administrative Director Jennifer Lutgens. There are more than 1100 house staff in over 100 residency and fellowship programs.
The information provided below will serve as a reference for Program Coordinators to know who within the GME Office can assist with a particular issue. This is not a complete listing of duties and responsibilities but only a reference guide for items the coordinators may need from GME.
GME Office Location and Contact Information: 209 Light Hall 2215 Garland Ave Nashville, TN 37232-5283 phone: 2-4916 fax: 3-1496 [email protected] https://www.vumc.org/gme/
Who to Contact in GME
Staff Member Areas of Responsibility
Kyla P. Terhune, MD, MBA FACS
Please contact Dr. Terhune with any questions or concerns that your Program Director is not able to address such as items
Vice President for Educational related to: Affairs, Associate Dean for • ACGME Graduate Medical Education • Site Visits ACGME / NRMP Designated • Internal Reviews Institutional Official • Program Requirements Associate Professor of Surgery • Program Letters of Agreement and Anesthesiology • Graduate Medical Education Committee [email protected] Dr. Terhune’s appointment calendar is maintained by Yvonne
Snyder.
Jennifer Lutgens
• •
•
Overall management of GME GME office procedure, planning, development, implementation Contracts
Administrative Director • HR policy implementation including FMLA, LOA, etc. 2-4916 • Training programs [email protected] •
• • •
House Staff Orientation Coordinator Meetings/Needs House Staff Payroll/Salaries Budget
• Call Rooms • House Staff Problems or Concerns • J-1 Visa Processing and general visa questions/issues for
house staff • GI Bill Certification for house staff • Any other questions or concerns not listed
Sonja Bogich Administrative Assistant 2-7820 [email protected]
• External requests for verification of training for current/archived house staff
• Licensure verification • Verification of training dates for Risk Management • Loan deferments • House staff budget reconciliation • Space inventory • White coat ordering (requested via house staff portal) • Front desk back up • Other administrative duties (JE’s, 1180’s, check requests
and deposits)
Megan Whitey Program Manager 2-0469 [email protected]
• Internal reviews • Website updates • New House Staff Orientation • GMEC and Expansion meetings • Coordinator and House Staff Manual Updates • Applicant Code and Duty Hour Monitoring Reports • Program database and e-mail lists • Program Letters of Agreement • Meal money back-up • CLER visits • J-1 Visa back-up
Thu Dang Senior Application Developer [email protected]
• Development of computer-based applications related to GME
• Reports from GME database • House staff and coordinator portals • Data importation from match application • Analysis of issues related to GME applications • Data Analysis for house staff compliance • VUMC ID and clinical systems security management • New Innovations support (backup) • Management of House Staff Meal money
Lisa King Associate Program Manager 2-7061 [email protected]
• Moonlighting Approval Process and Requirements • Visiting Residents • ID Badge processing for house staff • New hire welcome packets • Certificates • Recruiting materials • Call room maintenance • House Staff exiting process • Processing of FMLA for house staff
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•
• •
COI house staff compliance IHI online module compliance Supply ordering
Audrey Patrick
• • •
•
Credentialing for incoming house staff Appointment letters and contracts Reappointments, training extensions, and transfer processing for existing house staff Advancement process for existing house staff
Senior Program Manager 2-7821 [email protected]
• • •
•
•
Managing House staff data in GME database Pay actions for house staff Position request forms/Budgets for GME house staff salary centers FMLA process for house staff (back up) Facilitation of trainings for Program Coordinators and updates/emails to Program Coordinators
Yvonne Snyder
• Communications with Associate Dean’s office/scheduling/questions/requests
2-6035 • HSAC, House Staff Focus Group, and PD meetings [email protected] •
• Chief Residents’ Leadership Workshops Research Forum
Mischon Ramey
• •
New Innovations management and training Reports from GME database
Senior Application Developer 3-1678 [email protected]
• • • • •
House staff and coordinator portals GME database management New computer-based applications related to GME Analysis of issues related to GME applications Resuscitation compliance tracking
Benita Stubbs • Monthly Meal Money Usage Report Budget/Accounting Analyst (Part- time) [email protected]
• • •
Approval of moonlighting pay for house staff Monitoring GME budgets Audits for GME areas such as pagers
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Program Coordinator Manual 8
Duties of the Program Coordinator
This section is not meant to be a job description, but rather a list of some of the duties common to all or most coordinators.
• Compile and submit reports to ACGME, GME
• Maintain GME Track
• Initiation and administration of house staff budget
• Compile data and prepare reports for numerous organizations
• Development of new procedures in response to new or revised policies issued by governing agencies or program director
• Liaison with residents
• Plan, organize and schedule new house staff departmental orientation
• Liaison and communication with all appropriate campus offices and affiliated hospitals as well as program director
• Coordination and administration of specialty board examinations and in-service examinations
• Review of internal procedures related to all house staff-related functions and implementation of new procedures as appropriate
• Review all residency applications and screen those appropriate for interview. Evaluate residency applications for competitiveness for program, and notify applicants of decision.
• Use knowledge of ERAS® software to manage residency applications and compile reports as necessary.
• Write and revise recruitment brochures and all printed materials and forms, as well as all Web site information
• Administration and coordination of all house staff interviews; communication with applicants as necessary and appropriate
• Prepare and distribute rotation schedules
• Schedule and distribute resident conference schedules
• Track and log all vacation/sick leave used by house staff in Kronos
• Prepare resident travel authorization; arrange travel for conferences
• Complete verification requests from former residents
• Maintain files on all residents
• Prepare monthly reports on case logs and duty hours for program director Maintain rotation information and any other items required by your program in New Innovations
• Arrange for radiation dosimetry monitoring and annual fit testing for house staff if required
• Milestones Review and Clinical Competency Committee (CCC) meeting coordination
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A Year in the Life of a Residency or Fellowship Program
Note: key dates for GME items are in red below
July • July 1 is the beginning of the academic year in all GME programs. It is the date most new residents and
fellows begin their training. • Host department orientation
• Annual ACGME ADS update and GME Track update of the resident census generally begins in the summer. You will receive an e-mail notifying you that the census is ready to be updated.
• Begin the process of answering questions about your Residency Program from 4th year medical students
• ERAS opens in mid-July for fellowships
August • Submit match quotas to NRMP
• Complete GME Track and ACGME ADS updates for the new academic year. Archive past residents by August 1, enter new information by September.
September • ERAS opens mid-September for residency application. It is helpful to meet with your program director
to discuss the best process for screening applications.
• Prepare recruitment materials (Request grey zipper bags from GME for your recruitment materials)
• Assemble any other packets or materials to be distributed to residency candidates
• Make preparations and schedules for upcoming interview season
• Update all interview materials including Interview Evaluation Forms
• Determine interview date(s), if not already done. Notify faculty and appropriate personnel both administrative and clinical.
• Secure venue for entertaining applicants, if applicable
• Begin to send out invitations to interview
October
• If your faculty uses ERAS® online for interviews, orient new faculty
• Plan and coordinate social activities for applicants
• Registration for in-training exam is usually in the fall, although this varies among specialties
• Prepare for applicants to call to check their status updates and to find out if they will be offered interviews
November
• Medical student performance evaluations (formerly “Dean’s Letters”) are released October 1
• Assist during interview days by developing itineraries, greeting applicants, and providing an overview of the program
• Coordinate with faculty in interview process by providing them with applicant information
• Coordinate scoring of applicants
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• Fellowship rank list due either last week of November or first week of December
• House Staff Paid through GME Centers – HOUSE STAFF POSITION REQUESTS will be distributed by GME late November. Due to GME mid-December.
December • Interviews continue
• Mid-year evaluations (semiannual)
• Send out letters of regret to those applicants who have not been selected to interview
• Fellowship Match day is mid-December
• Position Request Form will be due to GME mid-December.
January • Finish with interviews
• Coordinate “second look” visits from applicants (if your program allows)
• Collect final scores and comments from interviewers and residents
• Continue letters of regrets to applicants who have not been selected to interview
• Note deadline for NRMP match quota changes
• On-Line ADVANCEMENT FORM released- Due to GME Feb 1st.
• Begin submitting required appointment information for Non-match applicants to the GME office. (January-February)
• Begin submitting Clinical Fellow re-appointment materials to the GME office. (January-February)
February • Coordinate match list
• Enter match list on NRMP web site
• Register your programs for ERAS® for the following year
• Schedule Program Education Committee meetings or faculty meetings to systematically review your programs, make curriculum decisions for upcoming year and evaluate resident performance. This is an ACGME requirement.
• On-Line Advancement Form due to GME February 1st.
March
• Match Day occurs in mid-March. Results are posted on the NRMP web site.
• Submit required information regarding match applicants to the GME Office.
• Prepare checklist of all tasks to complete for incoming and outgoing house staff.
• Begin appointment process for new house staff. Mail out packets with necessary forms and information
• Update web site, if necessary
• Generate lists of residents for next academic year and distribute to appropriate personnel and departments
• J-1 Visa: Communicate to Jennifer Lutgens via e-mail any new or continuing house staff who need J-1 sponsorship by March 24
• All appointment requests for incoming house staff should be submitted to the GME Office by March 1st.
• All Clinical Fellow re-appointment materials for current house staff should be submitted to the GME office by March 1st.
• Once you know who will be entering your program, submit your APPLICANT CODE REPORT to GME.
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April • Begin updating Goals and Objectives, Policies and Procedures, etc.
• Secure venue for graduating residents’ banquet.
• Begin to schedule meeting for late May or early June to hold your PEC
• New Hire PAF’s due to GME by April 30 for regular on-cycle hires. o If local address not available, use your department address (not GME) o Include SS# (if available) and birth date o Citizenship – US or Alien (not yes/no, country, or Visa type)
• Notification will be sent from GME to Program Coordinators when Welcome Packets have been mailed to incoming house staff. This notification will also provide a web link where you can monitor your incoming house staff pre-employment requirement completion status. It is important for you to assist the GME Office in obtaining all items so your House Staff can begin training on time.
• GME CERTIFICATE data will be sent to programs for review late-April. Upon confirmation, certificates will be provided for signature rounding.
May • You and the Program Director will receive periodic emails informing you of items needed for your
incoming house staff May/June. It is important for you to assist the GME Office in obtaining these items so your House Staff can begin training on time. You may view missing/received items at the link e- mailed to you in early April.
• Prepare resident rotation schedule for upcoming year. Create new academic year in NEW INNOVATIONS
and begin to enter rotation block.
• Plan events for graduating residents and fellows
• Order certificates and/or plaques for graduating residents and fellows
• Update and print resident manual for the next academic year
• Begin to work on Annual Program Evaluation (APE) in early May once ACGME surveys are back
• Prepare and distribute annual evaluation forms of program and core faculty to residents
• Coordinate residents’ semi-annual reviews for non-graduating residents
• MEAL MONEY process will begin with e-mail sent from GME to Program Coordinators. Provide requested information by June 15 if residents are to have money on July 1.
• Begin submitting payroll items (Transfer PAF, ePAC actions) for GME approval. EDCs are due in ePAC by June 1.
June
• Make request to GME for additional PAGERS or pager transfers as appropriate.
• Payroll actions due by June 10th for GME Approval: o ePAC actions due for GME approval to advance house staff who are remaining in the same
program o Paper PAF’s due to GME for House Staff who are transferring to another GME program or a
faculty position at VUMC. o ePAC action due for GME approval to terminate house staff leaving Vanderbilt.
• GME certificates released to programs mid-June. • Finalize Goals and Objectives, Policies and Procedures and other program documents for distribution
to new house staff
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• Prepare new rotation schedule for next academic year and disseminate to necessary staff
• Coordinate department orientation program for new residents and fellows
• Coordinate graduating residents’ year-end summative evaluation meetings with Program Director
• Graduation ceremony
Various
• Fellowship and Non-NRMP program applicants and interviews. For NRMP Fellowship dates see this chart: http://www.nrmp.org/wp-content/uploads/2015/03/SMS-Master-Calendar.pdf.
• INTERNAL REVIEWS
• Keep WebADS current with any change in the program and update at least annually.
• Off-Cycle Hires – process items above (new hire PAF, etc.) depending on start date.
• VISITING RESIDENTS – initiate contract 90 days in advance of rotation if needed.
• PROGRAM LETTER OF AGREEMENT (PLA) must be renewed/re-signed every 5 years.
• AWAY ROTATIONS (domestic or international) require an approval request from the resident/fellow on the GME Away Rotation Management System. The coordinator must also submit a contract request through PEER (Paperless Environment for Electronic Review) within the appropriate time frame (90 days in advance of rotation for domestic rotations and 120 days in advance of international rotations).
• Arrange for radiation dosimetry monitoring and fit testing for house staff if needed. See www.safety.vanderbilt.edu for more information.
Program Coordinator Manual 13
ERAS® - the Electronic Residency Application Service
The Electronic Residency Application Service (ERAS®) streamlines the residency application process for
applicants, their Designated Dean's Offices, Letter of Recommendation (LoR) authors and program directors. By providing applicants the ability to build and deliver their application and supporting materials individually
or as a package to programs, ERAS provides a centralized, but flexible solution to the residency application and documents distribution process.
Not all programs use ERAS®. Some programs take applications directly, or through the San Francisco Match. ERAS® began operating in 1995. Since its introduction, ERAS® has added additional specialties and accommodated more applicants.
ERAS® Applications
ERAS includes four individual, but connected, applications developed to serve the needs of each user group involved in the application process and provide impartial, confidential transmission of applications to programs:
• MyERAS for applicants, in which students complete their applications, select programs, assign supporting documents, and submit their materials to their selected programs
• Dean's Office WorkStation (DWS) for Designated Dean’s Offices to upload medical school transcripts and medical school performance evaluations (MSPEs) in support of applications submitted through MyERAS
• Letter of Recommendation Portal (LoRP) for LoR authors to submit letters in support applications submitted through MyERAS
• Program Director's WorkStation (PDWS) for training programs to receive and review the applications and supporting documents
For help adding a program, updating information or to gain access to ERAS, contact Megan Whitey in the GME office.
How Does ERAS® Work?
• Applicants receive a token from their Designated Dean's Office and use it to register with MyERAS.
• Applicants complete their MyERAS application, select programs, assign supporting documents, and apply to programs.
• Applicant’s Designated Dean’s Office and LoR authors upload supporting documents.
• Examining boards receive and process requests for transcripts.
• Programs receive application materials through the PDWS.
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ERAS® User Manuals and Website ERAS® software is designed to be easy to use, and most users agree. ERAS® has user manuals, online help and a tutorial to help new users get started. ERAS® has a web site with up-to-date information at www.aamc.org/eras. Training help for ERAS® for Programs can be found at this page: https://www.aamc.org/services/eras/programs/training/.
Roles and Responsibilities of the ERAS® Players There are six major participants in the ERAS® process each with special roles. A clear understanding of the responsibilities of each participant will help when establishing guidelines and policies for using ERAS® at individual programs.
It is the applicant’s responsibility to contact each residency program for requirements, deadlines, and program information. Applicants obtain a token from their designated Dean’s office which allows them to access the MyERAS web site and complete the application form. In addition, applicants are expected to request and assign all supporting documents before submitting their applications to programs. It is extremely important for the applicant to ensure that the application is complete, all deadlines are met, and fees paid. Finally, applicants should track the delivery of their documents and follow up, when necessary, with their Dean’s office and/or residency program.
Medical schools establish local policies and procedures for processing applications using ERAS®. It is the school’s responsibility to support applicants in the application process. Schools must download applicant files, and scan and attach documents to the applicant files. Schools provide official transcripts and authentic MSPEs via their ERAS® software. Schools do not verify the authenticity of letters of recommendation they receive and transmit. As in the traditional paper system, it is the responsibility of the residency programs to review these letters. Finally, schools back-up their data on a daily basis, and inform the AAMC of any problems.
ECFMG acts as the designated Dean’s office for all IMGs (graduates of medical schools outside the US and Canada). ECFMG is responsible for transmitting USMLE transcripts to programs as instructed by applicants. They also transmit and update an official ECFMG Certification Status Report. ECFMG does not, however, authenticate transcripts, MSPEs, or letters of recommendation received by applicants. These documents are often sent to ECFMG from the applicants and are scanned by ECFMG as copies rather than original documents.
NBME is responsible for transmitting USMLE transcripts to programs as directed by applicants. When electronic copies are unavailable, NBME will send paper transcripts for NBME Part or NBME / USMLE Step combination tests. NBME also updates scores as requested by applicants.
Residency programs are responsible for learning how to navigate ERAS and teaching each user how to appropriately review applications. It is also their responsibility to communicate with applicants regarding processing files at their program. Residency programs must back-up PDSW data for their security and inform AAMC of any problems.
AAMC’s role in ERAS® is to provide software, manuals and instructions to users. AAMC is tasked with providing technical and procedural support to schools and programs. Most importantly, AAMC ensures the reliability and security of file transfer of application material.
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Recruitment and Selection
The GME Recruitment and Selection policy is located in the House Staff Manual: https://prd-medweb- cdn.s3.amazonaws.com/documents/gme/files/HS%20Manual%20-%20FINAL.pdf.
Most residents are selected through a formal matching process. The majority of residency applications are uploaded into the Electronic Residency Application Service (ERAS® - covered in previous section). ERAS® transmits a standardized application, letters of recommendation (LoRs), the Medical Student Performance Evaluation (MSPE), transcripts, USMLE scores, and other supporting credentials from applicants and designated dean’s offices to program directors. Coordinators usually begin reviewing applications once they have opened (Fellowship opens July 15th and Residency opens September 15th).
Each program sets its own deadline for applications to be completed, but once complete, they are reviewed and selections are made for those applicants who are invited for an interview. The number of sessions and actual interview process is set by each program. Interviews are offered for predetermined interview sessions. These offers may be made by e-mail or regular mail. Phone calls are not recommended because there is no documentation of what is offered.
The GME office provides grey zipper bags and Newcomers Guides for use during your recruitment season. Contact Natalie Blair to set up a time to pick up these materials. This zipper bag is a good way to make sure that each applicant that interviews is given a copy of benefits information and a copy of a sample house staff contract. Both are available on the GME website. You are required to give these items to the interviewees.
The benefits outline (also linked above) https://www.vumc.org/graduate-medical-education/sites/default/files/public_files/Benefits-Outline-for-Recruits.pdf must be provided to applicants during the interview process. On-Cycle New Hires will sign up for benefits during Orientation and Off-Cycle New Hires will be referred to Human Resources for individual enrollment. Like all other employees, house staff must participate in the open enrollment period in October to update/renew their benefit selections.
Interviewing Don’ts
As part of preparing for interviews, make sure all faculty interviewers know what types of questions and topics or behaviors are illegal, inappropriate, and/or prohibited by NRMP. At the start of each interview season, all interviewers should see the list below as well as read the NRMP Communication Code of Conduct: https://www.nrmp.org/communication-code-of-conduct/
Interviewers must NOT discuss or ask questions regarding: • Age
• Marital Status
• Religion or Creed
• Gender
• Sexual Orientation
• Immigration Status
• Veteran Status
• Disability (it is permissible to ask about the applicant’s ability to perform the essential duties and responsibilities described)
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• Family Status (it is permissible to ask whether there are any activities, commitments, or responsibilities which might prevent the meeting of work schedule/attendance requirements, but only if asked of all applicants - both male and female)
• National Origin (it is permissible to ask about an applicant’s ability to read, write, or speak English or another language when required for a specific job)
Required Documentation of Selection Process for All Applicants Considered
The GME office is required upon request to provide VUMC with a listing of each program’s applicants and the reasons why applicants were or were not selected and the selection procedure. These two items together meet this requirement:
• Statement of your Selection Criteria and Procedures: This should be listed in your program’s policies and procedures or resident manual.
• Applicant Code Report (annual requirement) o Once your selections have been made, your rank list submitted, and your match completed,
compile a list of all of your applicants whose file you opened and/or reviewed to decide if you were going to invite them for an interview. If you use ERAS®, you can export data from there to form the basis of your Applicant Code Report.
o Code each applicant with one of the following codes and submit the resulting report to GME via the Program Coordinator Portal (https://gme.app.vumc.org/GMEPortal/Portal_PrgAdmin/ApplicantCoding.aspx):
1: Not invited – educationally less qualified than invited applicants 2: Invited – declined or canceled interview 3: Interviewed – not ranked or not offered a position (if the program does not use a
ranking system) 4: Ranked – did not match or did not accept position offered 5: Ranked and matched or accepted position offered
o If you have questions about the Applicant Code Report, please contact Megan Whitey ([email protected])
Applicant Record Retention Programs should maintain all paper and electronic applicant files for a minimum of three years. At that point, the program can choose to shred the paper documents if desired. Electronic data can be maintained after three years at the program’s discretion. It is suggested that programs maintain a listing of all applicants/candidates for each year for future reference/statistics.
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International House Staff
International Medical Graduates International Medical Graduates (IMGs) are physicians who received their basic medical degree or qualification outside the US or Canada. All International Medical Graduates (IMGs) must have a certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) certifying that they are approved to pursue graduate medical education training in the United States. In order to achieve ECFMG certification, international graduates must submit their credentials to the to the ECFMG and pass competency tests in both English and clinical skills. IMGs must obtain their ERAS® application kits from the ECFMG, which will issue them only to qualified applicants.
ECFMG Exam and Certification requirements:
• USMLE Step 1
• USMLE Step 2 (CK)
• USMLE Step 2 (CS)
• Primary source verification of final medical diploma and transcripts
• English test proficiency
Visas for International House Staff An International house staff usually holds one of these types of visa (or visa status):
• F-1 with OPT/EAD This status is commonly seen with someone who completed medical school in the USA. After completion of medical school the trainee is entitled to one year of optional practical training (OPT) and begins the residency program with an employment authorization document (EAD) that allows employment for one year. A resident on F-1 status must change to either a J-1 or H-1B status to continue residency training past PGY-1. Contact for the Resident and Program Coordinator for F-1’s: The international student office at the location they completed medical school.
• H-1 B (or E-3 for Australians) The H-1 B is an employment visa – house staff can be “employees.” This visa status is regulated by the Department of Homeland Security (US Citizenship and Immigration Services, Customs & Border Protection) and the Department of Labor (DOL). An H-1 B can be used for up to six years so persons in longer programs may need to move to J-1 status or obtain Permanent Residence. Every trainee that qualifies for H-1 B status can also get a J-1 but every trainee that qualifies for J-1 status cannot get an H-1B. Contacts for the Resident and Program Coordinator for H-1 Bs: Filing of all H-1 B petitions and extensions and E-3 petitions is initiated here: https://redcap.vanderbilt.edu/surveys/?s=MNPP39NHPP%20
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• J-1 ECFMG sponsors J-1 visa for House Staff. Jennifer Lutgens and Megan Whitey in the GME Office are Training Program Liaisons (TPLs) to the ECFMG. The J-1 visa is often preferred for house staff (no cost to the program). The process is outlined below.
GME Process for J-1 Visa J-1 Visa Status is a temporary, non-immigrant visa for full-time educational training-not employment. The J-1 has a two year home residency requirement with seven years maximum progressive training. There are three organizations and one federal agency involved in the J-1 visa process for IMG’s:
• Department of State – administers the Exchange Visitor (EV) Program (which includes the J-1 medical
training program.
• Association of American Medical Colleges (AAMC) – Monitors and sets standards for medical education and administers the Electronic Residency Application Service (ERAS®)
• National Residency Matching Program (NRMP) – administers the “Match”
• Educational Commission for Foreign Medical Graduates (ECFMG) serves as the Responsible Officer (RO) for the EV Program and provides academic credentialing services and issues the DS-2019. ECFMG is also responsible for authorizing travel for the J-1 trainee and issuing the ECFMG certification.
In order to be issued a DS-2019, an IMG must have ECFMG certification.
Each GME/Teaching Hospital has a designated Training Program Liaison (TPL) who works directly with ECFMG. At Vanderbilt, the TPL is Jennifer Lutgens, Administrative Director of GME.
There are three main types of J-1 Visa Applications.
• Initial Application
• Application for Continuation
• Non-Standard Training Program Application
All instructions are located on the ECFMG website: www.ecfmg.org The application process must be initiated by the TPL at the training institution.
Due Dates: For On-Cycle Hires, notify Jennifer Lutgens (TPL) at [email protected] of J-1 continuation or initial applications by March 24 of the hiring year. Please include the USMLE/ECFMG ID number in your email as this will be required for the on-line process. Jennifer will initiate an appointment profile and “add applicant” to the on-line EVNet system created by ECFMG. The current or incoming resident/fellow will then receive an email from ECFMG with instructions to complete the application process. Supporting documentation must be uploaded as part of the on-line process by both parties prior to the application submission so it is important that this process be coordinated with Jennifer Lutgens.
It is strongly recommended that the program generate an offer letter from the Program Director to the incoming house staff member to be signed by the applicant for acceptance and returned to Jennifer Lutgens.
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The letter must include specific start and end dates of the training year, Specialty and Sub-Specialty of the training
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program, training level (PGY Level) and stipend amount. This letter or the house staff agreement (contract) will be required before the on-line application can be initiated!
If the application is approved, ECFMG will issue Form DS-2019, Certificate of Eligibility for Exchange Visitor (J- 1) Status to the TPL (Jennifer Lutgens). Jennifer will provide the original to the applicant (by FedEx Airbill or, if already at Vanderbilt, have them stop by GME) with a copy to the GME file and a copy to the Program Coordinator for notification of the completed process and documentation for files. Unless your resident/fellow is on-site currently, please provide a FedEx Airbill addressed to the applicant to Jennifer Lutgens for mailing of the DS-2019.
Please note: • J-1 renewal is required annually.
• ECFMG requires 4-6 weeks for processing.
• By March 24th (date for on cycle hires) notify GME (Jennifer Lutgens) of any incoming or continuing house staff who need an initial or continuation of J-1 sponsorship.
• When the J-1 Physician reports for training he/she must present the TPL with evidence of approved J-1 Visa Status in order to begin the training program. Documentation includes J-1 Visa Stamp in Passport, J-1 D/D (Duration of Status) on I-94 Arrival/Departure Record. TPL Reports Arrival/Delay to ECFMG within 30 days.
Occurrences GME Must Report to ECFMG Any of the following changes must be reported to ECFMG by the TPL so it is imperative that you make sure GME stays informed.
• Remediation
• Leave of absence (including FMLA)
• Licensure delay
• Proposed Off-Site Rotations
• Proposed early advancements
• Resignations
• Contract Terminations
• Legal Concerns, Allegations, Internal Hearings, etc
• Travel
Additionally, please let Jennifer Lutgens know right away if you hear of any of the following incidents/allegations related to your J-1 trainee or their dependents that have a J-2 visa. These must also be reported to ECFMG by the TPL.
NATURE OF INCIDENT OR ALLEGATION
• Death of a J-1 physician or J-2 dependent
• J-1 physician or J-2 dependent is missing
• J-1 physician or J-2 dependent sustains a serious
illness or injury (i.e., brain injury, severe burn,
major surgery, communicable disease, serious
mental incidents, any condition requiring
hospitalization of 48 hours or more, etc.)
• Incident involving the criminal justice system
(i.e., arrest, charges, law enforcement, etc.)
• Sexually-related incidents or abuse (an incident
or allegation involving sexual exploitation,
harassment, or abuse)
• Negative press involving a J-1 physician and/or
J-2 dependent(s)
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• Litigation (in which the J-1 physician or J-2
dependent is named a party, including
malpractice)
• Foreign government involvement (including
embassy officials)
• Other situations impacting a J-1 physician’s or J-
2 dependent’s safety (i.e., natural disaster, civil
unrest, outbreaks of violence)
Contact for the Resident and Program Coordinator for J-1’s: Jennifer Lutgens (TPL).
Other Visa Options Other visa statuses possible, but far less prevalent, include L-2, E-3D J-2, pending PR with EAD, etc.
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The Match
For most coordinators, “The Match” means the National Resident Matching Program (NRMP). (Other programs may come through something called The San Francisco Match, or might select their applicants apart from any match.) The NRMP is a private, not-for-profit corporation established in 1952 to provide a uniform date of appointment to positions in GME. Five organizations sponsor the NRMP: the American Board of Medical Specialties (ABMS), the American Hospital Association (AHA), the Association of American Medical Colleges (AAMC), the American Medical Association (AMA), and the Council of Medical Specialty Societies (CMSS). Each year the NRMP conducts a match that is designed to optimize the rank ordered choices of students and training programs. In the third week of March, the results of the Match are announced.
The NRMP is not a centralized application service for GME programs and cannot advise applicants in selecting specialties or programs. The NRMP is simply a mechanism for the matching of applicants to programs according to the preferences expressed by both parties.
Programs accredited by the ACGME are eligible for participation in the NRMP. Institutions wishing to offer residency positions in the Match must register their program annually. As a result of participation in the NRMP, hospitals enrolling programs in the NRMP agree to select senior student applicants in U.S. allopathic medical schools only through the Match in accordance with the policies established by the NRMP. Positions may be offered through the Match to physician graduates of U.S. and Canadian schools of allopathic medicine, U.S. schools of osteopathic medicine, and schools of medicine located outside the U.S. and Canada who meet eligibility requirements set forth by the NRMP.
An annual schedule of dates is published by the NRMP on the NRMP web site here: http://www.nrmp.org/match-calendars/. Adherence to these dates is essential. Materials must be received by the NRMP by the published deadlines. Note: Dates will change from year to year so always reference the website for current information.
The listing of an applicant by a program on its Rank Order List or of a program by an applicant on the individual’s Rank Order List establishes a commitment to offer or to accept an appointment when a match results.
Under certain conditions, applicants may withdraw from the NRMP, provided such withdrawal occurs prior to the Rank Order list submission deadline. Applicants who have accepted a residency position through any previous match or outside the NRMP Match must withdraw from the NRMP; or if the position secured is for an advanced program the applicant can only rank first year preliminary or transitional programs.
The NRMP website has additional resources for new program staff on this webpage: http://www.nrmp.org/new-program-basics/.
All-In Policy Any program that participates in The Main Residency Match must register and attempt to fill all of its positions through The Match or another national matching plan. A “program” is defined by its ACGME number. The All-In Policy applies to positions for which the NRMP offers matching services, including PGY-1, PGY-2, and in the case of Child Neurology, PGY-3 positions. All PGY-1 positions and PGY-2 positions in specialties that can
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begin at either the PGY-1 or PGY-2 level must be placed in the Match, regardless of whether the program begins in the PGY-1 or PGY-2 year. Programs can create “Physician Reserved” (“R”) program tracks in the Registration, Ranking, and Results (R3) system for applicants who are eligible to begin advanced training in the year of the Match. PGY-2 or higher positions, in specialties accredited to begin only at the PGY-1 level, and PGY-3 or higher positions in specialties accredited to begin at either the PGY-1 or PGY-2 level are not subject to the Policy because the NRMP does not match for those positions.
Fellowship Match sponsors may voluntarily implement the All-In Policy.
Programs may withdraw, or may withdraw positions, from the NRMP, provided such withdrawal occurs prior to the date established by the NRMP, and published as the final date for changes in programs and/or available positions for the NRMP. The registration fee paid by applicants and the GME office is nonrefundable.
For more information, please see http://www.nrmp.org/all-in-policy/.
Supplemental Offer and Acceptance Program (SOAP)
Note: SOAP-eligible unmatched applicants shall initiate contact with the directors of unfilled programs only through ERAS. Other individuals or entities shall not initiate contact on behalf of any SOAP-eligible unmatched applicant prior to contact from directors of unfilled programs. Such contact is a violation of the Match Participation Agreement: http://www.nrmp.org/program-inst-match-participation-agreement/. Contact between programs and matched applicants prior to the general announcement of Match results at 1:00 p.m. eastern time on Match Day also is a violation of the Match Participation Agreement.
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New Hires
Now that your match is complete and you know who your new house staff will be, it’s time to formally hire them. For programs that use the National Residency Matching Program (NRMP), immediately after the match, you must do the following (detailed request with instructions will be emailed to you):
• Provide requested information to the GME Office regarding those who matched
• Indicate in ERAS® PDWS which applicants have matched with your program
• Provide a hard copy of the matched ERAS® applications to GME Office
For those programs that use a match program other than the NRMP, or do not use a match system at all, you must submit a hard copy of each new hire’s application packet in February and no later than March 1st
(Vanderbilt or ERAS®) containing the following as soon as possible:
• VUMC or ERAS® application
• Current CV
• Copies of 3 recommendation letters
• Copy of ECFMG CERTIFICATE (if graduate of a medical school outside the US and Canada)
• Copy of H1-B or J-1 visa (if applicable)
• For residents accepted outside of a normal match period for your program or transferring from another institution – Program Director sends a request for an appointment letter to Dr. Terhune (must include program name, time period, post graduate year level, and salary)
• For clinical fellows – Division Chief or Department Chair sends a letter requesting appointment addressed to Dr. Terhune (must include: program name, one-year appointment period, PGY level, salary, and funding source)
In early April of each year, the GME office sends out GME Welcome Packets to all incoming house staff containing and/or requesting the documents and information detailed in a task list on the GME Portal. Only incoming house staff can see the task list in the portal, but as a guide to its contents, Program Coordinators and Directors can reference the most recent final task list here: https://prd-medweb- cdn.s3.amazonaws.com/documents/gme/files/PreEmploymentChecklistFinal.pdf. Requested information must be returned promptly based on the timeline. Not all information (e.g. final transcript) will be available immediately but should be sent as soon as possible to avoid delays in start date. E-mail reminders will be sent beginning in June to Program Directors and Coordinators to assist with any missing items from new hires. To check what items GME is waiting on for your incoming house staff, see this link: https://gme.app.vumc.org/reports
New Hire Payroll A New Hire Personnel Action Form (PAF) must be completed end of April (on regular hire cycle) for each new resident and turned in directly to GME. A reminder to do so will be sent out in April to those who have not submitted. Please pay close attention to ensure the correct job code, start date, and center numbers are entered, specify male or female, citizenship (US or Alien), and include a local address (or your department office address if local address not available). Never use “postal” in the mail drop box. This will cause the first paycheck to be mailed to the resident mailing address instead of the department mail drop.
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If your new residents attend the GME New Resident Orientation, they may qualify for Orientation Bonus. This is only for individuals not currently on the VUMC payroll. Residents must attend the full three day orientation to qualify for the Orientation Bonus. GME will verify orientation attendance, eliminate those who are already on the VUMC payroll transferring from another department, and process the additional pay directly with payroll.
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Miscellaneous
Annual Program Evaluation The Annual Program Evaluation (APE) is a requirement for all ACGME-accredited programs and is reviewed by the Graduate Medical Education Committee (GMEC). It is the Program Director’s responsibility to complete the APE each year and must be completed even if there were no trainees in the program for the year. Only program directors will have access to complete this evaluation in New Innovations.
Call Rooms ACGME Institutional Requirement II.F.2.b. requires that “residents on call must be provided with adequate and appropriate sleeping quarters that are safe, quiet, and private.” The GME Office is responsible for house staff call rooms assigned to GME on the hospital space inventory. GME assigns the rooms to programs based on need and available space. GME provides the basic furnishings and should be contacted if there are problems with a call room. Each program should make sure that their house staff know where their call room is located.
Computer Systems Access The GME Office requests computer access for all clinical systems during the appointment process for all house staff including off-cycle hires:
It is not necessary to complete a “Systems Access Form” for new hires or terminating house staff. GME will carry out the process. Access will be terminated on end date of GME appointment at midnight.
House Staff Member Request to Review GME File – Procedure to be followed When a member of the house staff makes a request to review the GME file please notify the GME Administrative Director or DIO as the file should first be reviewed internally. An appointment will be scheduled with the individual house staff member and someone will sit with the HS (usually the Administrative Director) to allow them to review the approved file. The house staff member will not be allowed to take anything from the file, have copies or take photos of any contents of the file. They can take notes. If any questions arise during the review the DIO should be contacted and will respond to the house staff member. See Appendix I for VUMC GME Records Retention Worksheet for Programs
House Staff Member Request to Review Program File – Procedure to be followed House Staff members may make request to review their program file. If this occurs the PD should be notified as well as the GME office (DIO, Administrative Director or Sr. Program Manager). The GME office will likely want to review the program file and may consult with the program director and legal counsel. An appointment should be scheduled with the House Staff member to review the file (in the GME office) with a staff member present (designee of the DIO). The house staff member will not be allowed to take anything from the file, copy anything or take photos of anything in the file. They may take notes while reviewing the file. If any questions come up the DIO or Program Director should be consulted.
See Appendix I for VUMC GME Records Retention Worksheet for Programs
Moonlighting For the purposes of GME, moonlighting is practicing medicine for pay outside the requirements of the training
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program. Please reference the House Staff Manual (https://prd-medweb- cdn.s3.amazonaws.com/documents/gme/files/HS%20Manual%20-%20FINAL.pdf) or the GME website (https://www.vumc.org/gme/13511) for information on moonlighting. All moonlighting must be included in resident/fellow duty hour tracking. Moonlighting approval questions can be directed to Lisa ([email protected]). Moonlighting pay questions can be directed to Audrey ([email protected]) or Benita ([email protected]).
Napping and Transportation Options for Post-Call Residents For house staff who are too fatigued to safely return home, several options are available through the Office of Graduate Medical Education including:
• Call Room Space available on an as needed basis for residents who are too fatigued to safely return home.
• Evening/weekend transportation home with a return trip the next day is available through Music City Taxi Company from VUMC or any affiliated site at which residents rotate.
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More detail can be found in the House Staff Manual at https://prd-medweb- cdn.s3.amazonaws.com/documents/gme/files/HS%20Manual%20-%20FINAL.pdf, under “Sleeping and Transportation Options for House Staff Too Fatigued to Return Home Safely.”
NPI Numbers The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.
The new residents will set these up themselves (instructions provided in the new hire information GME communicates to incoming house staff), but they sometimes forget their number. You or the residents themselves can look up their NPI numbers by searching the NPI registry website at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.
Pagers
Pager Assignment for all GME-appointed house staff Each department is responsible for assigning pager numbers for advancing and new house staff (both residents and clinical fellows). These numbers should be entered in the Coordinator Portal (https://gme.app.vumc.org/GMEPortal/Portal_PrgAdmin/Pager_Update.aspx) no later than mid-May for the July 1 transition. Select “Update Pager Numbers”, edit/enter pager information, then click “Save Numbers”. GME will then provide this information to the Satellink Office at Vanderbilt, VUMC Operators, and NotifyMD (after-hours answering service). Your department may require you to provide a list to additional groups.
Resident Pagers
• Pagers for residents stay within the same program, being reassigned from residents completing/leaving the program to residents starting the program. Residents are not able to keep the same pager if continuing at VUMC in another program or as faculty. As residents leaving the program check out, collect their pagers and distribute to your incoming residents according to the assignments you reported in the Coordinator Portal (https://gme.app.vumc.org/GMEPortal/Portal_PrgAdmin/Pager_Update.aspx)
• If additional pagers are needed for your residents, e-mail your request to Jennifer Lutgens at [email protected]. After approval and issue of the pager, you will receive an e-mail that the pager is ready for pickup at the Satellink Office located at D-2103 Medical Center North.
• If you have a pager that is paid for by GME but is not assigned to a resident, please return it to the GME Office.
• The GME office will periodically perform a pager audit to ensure that all pagers paid by the GME cost center are accounted for in the individual programs.
Clinical Fellow Pagers
• Pagers for clinical fellows are paid for and requested by the department directly with AQUIS/Satellink.
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Contact information for the Satellink Office at Vanderbilt is: D-2103 Medical Center North
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Hours are 8:00am-4:30pm, Monday-Friday 615-322-6477
Tennessee Medical License Exemption The GME Office applies for exemption from licensure for all new house staff (as well as continuing and visiting residents from out of state). Verification of exemption is maintained in the GME Office. If verification of exemption is needed, please contact the GME Office (for GME appointed house staff).
All house staff members who apply for MOONLIGHTING (internal or external) must have a full Tennessee Medical License and provide the license number on the application for moonlighting. The license exemption will not apply to moonlighting.
V-Net Codes To facilitate long distance calls related to patient care the GME Office requests V-Net Codes for all house staff and provide notification of these codes. If a resident is terminating from GME but staying at Vanderbilt, a new cost center will need to be provided to maintain the code but charge the department instead of GME. A requisition must be submitted to ITS to change the code to the new cost center. At the end of July a termination report will be sent to ITS to delete any V-Net codes for exiting house staff who are still being charged to our cost centers.
House staff should be advised that under no circumstances should a personal long distance call be charged to VUMC. Making unauthorized long distance calls is contrary to VUMC policy and may result in disciplinary action, including dismissal. Please reference the House Staff Manual for policy related to V-Net codes.
VUMC ID One of the most crucial parts of the new hire profile set up is the VUMC ID. This allows VUMC employees to access the VUMC domains, including computers, email, HR, and New Innovations. To facilitate computer systems access the GME Office makes the request to ITS for the VUMC ID to be created. House staff are instructed by the GME office how to establish an e-password. At that time they can obtain their VUMC ID. Please contact Jarrett Lea or Thu Dang for any issues with the VUMC ID.
Vacation Vacation time is awarded based on the appointment period instead of July-June. All house staff are awarded 120 hours of vacation time at the beginning of the appointment year and vacation will be pro-rated for partial year appointments. Vacation must be used within the appointment period and will not carry over to the next appointment period.
Kronos timekeeping for House Staff It is the responsibility of the program coordinator to track time off for house staff in Kronos. Please be sure to use the appropriate pay codes for house staff time off (as they are on the sick and vacation system instead of PTO). All Kronos resources including the form to grant access as well as the house staff pay code list are located here: https://hr.vumc.org/systems/kronos/reference
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White Coats Fellowship programs in which fellows’ stipends are not paid from GME centers are responsible for supplying coats for their fellows. GME orders coats for all residents plus fellows whose stipends are paid from GME center numbers (see chart below). These house staff request coats from GME through the House Staff Portal (https://gme.app.vumc.org/GMEPortal/Portal_HS/Portal_HS.aspx) . They get two coats initially that are then replaced if they become stained, otherwise ruined, or lost/stolen. A reason must be given to indicate the need for a replacement coat. House staff should allow two months turnaround time for any replacement orders.
Programs with white coats paid by GME Office
CHILD AND ADOLESCENT PSYCHIATRY
CHILD NEUROLOGY
DERMATOLOGY
DIAGNOSTIC RADIOLOGY
EMERGENCY MEDICINE
GENERAL SURGERY
INTERNAL MEDICINE
INTERNAL MEDICINE/PEDIATRICS
INTERVENTIONAL RADIOLOGY
NEUROLOGY
NEUROSURGERY
NEUROTOLOGY
NUCLEAR MEDICINE
OB-GYN
OPTHALMOLOGY
ORAL AND MAXILLOFACIAL SURGERY
ORTHOPAEDIC SURGERY
OTOLARYNGOLOGY
PATHOLOGY
PEDIATRIC OTOLARYNGOLOGY
PEDIATRIC UROLOGY
PEDIATRICS
PSYCHIATRY
PHYSICAL MEDICINE & REHAB
RADIATION ONCOLOGY
SURGICAL CRITICAL CARE
THERAPEUTIC RADIOLOGICAL MEDICAL PHYSICS
TRAUMA SURGERY
UROLOGY
VASCULAR SURGERY
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Identification Badge/VUMC Badge Bucks
For the incoming house staff who start in July or August and those changing program/title in July or August, the GME Office will provide a list of all eligible house staff to the Medical Center Card Office. The house staff will receive their ID badge during their new house staff orientation.
The Card Office will issue off-cycle house staff and visiting house staff badges when an ID authorization form is presented with the signature of someone in the GME Office.
Building Access If any of your house staff have issues with building access, please have them contact [email protected].
Meal Money The GME Office provides funds for meals during some call hours. Residents with in-house call that falls into one or more call categories defined below are issued a Vanderbilt Meal Money account for use on meals anywhere on the Medical Center campus that accepts the VUMC Badge Bucks, access this account by presenting your VUMC ID Badge. A maximum of $40.00 per day may be spent from the account. The dollar amount is reallocated each July 1st. Balances from the previous year do not carry forward.
Before each academic/fiscal year, the GME Office requests Program Coordinators submit projected total call amounts for each house staff for the approaching fiscal year. Meal money is then calculated by a formula according to how many meals the hours of call require. Provide the amounts of in-house overnight call, evening call, and morning call. Definitions are below.
• In House Overnight Call – House officer is required to stay 24 or more continuous hours: evening meal
and breakfast the next morning provided.
• Evening Call – House officer is on duty during the day and unable to go home before 8 PM: evening meal provided.
• Morning Call aka Evening Shift or Night Float – House officer is required to stay until 10 AM or later: breakfast provided.
For Meal Money for Visiting Residents/Fellows, see VISITING RESIDENTS/FELLOWS section.
Questions regarding GME meal money or VUMC Badge Bucks may be directed to Thu Dang at the GME Office ([email protected]).
House staff may also open a VUMC Badge Bucks account and add personal money for use when on call funds are exhausted. You may access and manage your account online at https://get.cbord.com/vumc/full/prelogin.php. VUMC Badge Bucks can be used only on Medical Center campus.
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Liability Coverage for House Staff
House Staff paid through GME Cost Centers The GME Office provides information to Risk Management regarding all new and continuing residents who have an appointment through GME. Those members of the house staff who are paid through the GME Cost Centers are covered with no additional paperwork. Risk Management sends a copy of the Certificate of Liability Coverage to GME which is maintained in the GME file.
Fellows Risk Management offers the following questions to assist you in determining if a provider needs individual trust coverage:
• Do they have clinical patient contact?
• Do they bill for their services?
• Do they consult or supervise residents?
If the answer to any of these questions is “yes,” they will need individual trust coverage. The Professional Liability Application must be completed and submitted to Risk Management as early as possible but within at least 30 days of the start date for Fellows to receive Professional Liability Coverage. Please provide the appropriate cost center for this expense as GME does not cover the cost. This document is located on our website at: https://prd-medweb-cdn.s3.amazonaws.com/documents/gme/files/LiabilityApplication.pdf
New Resident and Fellow Orientations
The GME Office provides three orientations for house staff new to VUMC each summer. All newly GME- appointed house staff are expected to attend an Orientation. Some individual departments also have orientation for new house staff. Orientation will serve to welcome new house staff, providing an overall introduction to Vanderbilt GME and specific training and information to cover many topics, including:
• Professional Responsibility
• Health and Wellness
• N95 Respirator Fitting
• Hospital Computer Systems and Required Training
• HR Benefits
• GME Check-In and Personal Information Update
• ID Badge
• Occupational Health Clinic for Immunizations, TB Test, etc.
• Patient Safety, Medical/Legal Liability
• OSHA and Infection Control
• International Tax (for international house staff)
• Payroll (completion of necessary paperwork including the I-9, W-4, etc.)
• White Coat Distribution for Residents (White Coats for Fellows are provided by the department)
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• Parking
The Resident Orientation is typically scheduled for June 24-26 (adjusted to weekdays when one or more of these dates falls on the weekend). The following two weekdays before July 1 are left for the programs/departments to hold their own orientations. The July Fellow Orientation for July-starting new fellows are usually July 1, and the August Fellow Orientation for August-starting new fellows is usually on August 1.
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New Innovations
New Innovations is the secure centralized Residency Management System (RMS) which the GME office has purchased for use by all programs. Program coordinators are required to use this system to report and maintain all annual rotation information. Please note the “Academic Year” is defined as July 1 - June 30. House staff members will use New Innovations to enter their duty hours, complete evaluations and other actions as designated by their programs. The system has numerous additional modules and features which you are free to take advantage of in the maintenance of your program but are not required for all programs. These include, but are not limited to, evaluations, procedure logging and reports, curriculum management, conference management, portfolio reviews, milestone tracking, and custom reporting.
New Innovations may be accessed here. For training and technical assistance please contact Mischon Ramey in the GME Office or contact New Innovations directly for general assistance at 330-899-9954. The functions and reports available in New Innovations are extremely helpful when preparing documentation for a site visit or internal review.
Individual Programs can use this Residency Management Suite to assist with scheduling, case logging, evaluations, monitoring conference attendance, duty hours and general personnel tracking. Examples listed below.
• Prepare and track RRC or Internal Review documentation, dates and results.
• Maintain affiliation agreements with automatic renewal reminders.
• Easily gather information from across the institution and conduct reporting for all departments.
• Customize reporting to address specific requests and provide relevant information.
• Send institution wide evaluations out to any set of individuals.
• Demographic centralization and customization help manage multiple aspects of medical personnel data.
• The IRIS (INTERN AND RESIDENT INFORMATION SYSTEM) MODULE allows GME and finance personnel to collect and export IRIS information for Medicare Cost Reports (additional detail provided later in this document).
More specific information regarding all that New Innovations offers can be found at the following link: https://www.new-innov.com/pub/
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Federal Funding, the Department of Finance and You: How Program Coordinators play a role in funding of GME
CMS (Center for Medicare and Medicaid Services) Center for Medicare and Medicaid Services (CMS) is the agency which reimburses the hospital to support the residency programs. CMS established an annual reporting process called the Intern Resident Information System (IRIS). IRIS must be used to collect Direct Medical Education funds (DME) and Indirect Medical Education funds (IME) funds.
All house staff time in the hospital is recorded in IRIS. Although house staff rotation information is recorded by residencies and fellowships based on an academic year, the IRIS report is submitted to Medicare based on the hospital’s fiscal year. Therefore, it is so important that all rotation schedules be maintained in New Innovations©. Coordinators should record leave times as well.
DME payments are made to cover Medicare’s share of a hospital’s overall cost to operate a resident training program. These costs include both direct expenses (e.g. resident compensation, teaching physician remuneration), and costs to operate the GME Office, plus hospital overhead to support resident training activities (e.g. administration, housekeeping, and information system costs).
IME payments from Medicare are intended to cover the “indirect” costs of GME. IME is calculated based on a complicated formula and is paid to teaching hospitals to recognize the higher operating costs that result from teaching activities.
New Innovations and IRIS (Intern and Resident Information System) The IRIS tools and reports are housed in the Finance module within New Innovations and allows GME and finance personnel to gather and export IRIS information for the CMS Cost Reports, based on the demographic and rotation information contained in the entire institutional database. The IRIS module is maintained by the GME office.
For accurate IRIS reporting, the rotation/block schedules in New Innovations must be kept as up to date as possible. This requires a 365 day “gap free” schedule or training plan for each resident/fellow. Gap analysis by the GME office will occur every quarter and programs will be contacted if there are any gaps in the block schedule. By early May a rough final current year schedule must be completed and by the end of May all schedules must be finalized for the current year. This information is critical for GME to meet the cost report needs of the Department of Finance.
Budget Preparation for GME and the Coordinator’s Role Budgets for resident salaries and benefits are prepared by GME based on information submitted by the department. These budgets are submitted to the Department of Finance for Hospital funding approval. Data for budget preparation is collected by departments using the House Staff Position Request Online Form and the Online Advancement.
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House Staff Position Request Form In mid-November of each year, House Staff Position Request Online form is distributed to programs with house staff paid from GME cost centers. This information is necessary to prepare the next fiscal year salary budgets submitted to the Department of Finance. Through this form online, the programs will provide details pertaining to the total number of residents, which PGY levels they will be appointed to, any non-Vanderbilt rotation sites, and any off-cycle or extension requirements. It is very important that these forms be accurate as this will cover the salary and benefits for house staff paid through the GME Office. Remember to include any house staff that may need to extend training beyond June 30th into the next fiscal year to cover the salary for the extension of training; otherwise, salary and fringe will not be budgeted to cover the extension of training for that individual. The position request form will be due to GME mid-December.
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Advancement
Advancing Current House Staff The purpose of the GME On-Line Advancement Form is for the program to provide and approve the next appointment status or end of training information for each of their current house staff in the next academic year. The on-line advancement system is accessible during the advancement cycle on the Coordinators’ Portal (https://gme.app.vumc.org/GMEPortal/Portal_PrgAdmin/Portal_PrgAdmin.aspx). The Administrative Manager in GME uses this information to prepare program certificates for house staff completing their training, prepare reappointment letters and agreements for those who will continue, anticipate receipt of clinical fellow reappointment documents and appointment request packets for those transferring into a new program, obtain exemption from medical licensure for continuing house staff, plan for required personnel/payroll actions, and to prepare the fiscal budget for those salaries/benefits paid through GME cost centers.
On-Line Advancement Form for All Programs An email with a link to the web application for the Advancement Form will be sent in December and will be due to the GME approval level by February 1st. The Program Coordinators are set up as “editors” on the Advancement Form. They can enter new appointment information as necessary. Program Directors are set up as “approvers.” Some programs require the approval of an AO/HR/Departmental person before the information is transmitted to the GME level. Should changes be necessary after submission to the GME level, please contact GME to have the form released for correction or further direction. Programs should submit the advancement information as soon as possible and must process the advancement so it reaches the GME approval level no later than February 1st. Information submitted on the Advancement Form must match information on the Annual Reappointment Form for Clinical Fellow/Clinical Fellow Trainee described below.
Reappointment Process Clinical Fellow and Clinical Fellow Trainee reappointments are requested via an Annual Reappointment Form of Clinical Fellows/Trainees. The original hard copy form and current CV must be submitted as soon as possible but no later than March 1st. Remember that the reappointment form may have to go to additional approvers before reaching the GME Office.
Reappointment request form: https://prd-medweb-cdn.s3.amazonaws.com/documents/gme/files/Reappointment%20Request%20-%20Fellows.pdf (fillable form)
The web-based Advancement Form is for the advancement of current house staff in both ACGME and non-
ACGME approved programs. New house staff (incoming to Vanderbilt) will not be available in the advancement system. Complete instructions will be sent with the email notification to begin completing your program advancement(s).
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Instructions for the Appointment Process and Compensation of House Staff who are supported by NIH Training Grants Residents and fellows that are appointed to NIH Training grants, such as T-32s or F-32s, are classified as Clinical Fellow/Resident Trainees (Job Code 9079). House Staff who are supported by NIH Training Grants now have only one appointment through GME unless a faculty appointment is required for the purpose of moonlighting. The NIH Stipend is paid through a stipend request form.
The department supplements the NIH Stipend with a salary which is calculated based on the difference of the NIH Stipend amount and the appropriate PGY level salary amount for House Staff at Vanderbilt (based on the House Staff Stipend chart published annually on the GME website).
The salary supplement will be paid on a PAF and any payroll deductions for benefits, taxes, etc. will be pulled from this amount. The monthly comp rate will be 1/12th of the annual salary supplement and the Benefits Salary will be the full House Staff salary amount based on the PGY level of the individual. The job code to be used on the PAF for these individuals is 9079 while they are supported by the NIH training grant and receiving a salary supplement.
Process • Appoint Trainee through NIH xTrain. Trainees will need eRA commons account set up prior to
appointment to the grant. Usually, department grant managers will facilitate this. • Complete stipend request and submit to Human Resources Processing.
o Stipend FAQs can be found here. o Current NIH stipend rates can be found here.
• Complete Paper PAF to bring salary to Vanderbilt PGY level, using job code 9079. Trainee benefits will be deducted from this portion of their payment.
If other support is provided by the department it should be paid on an additional pay form (APF), not the stipend request form and the purpose for the additional payment should be identified on the APF. All PAF’s and APF’s for house staff must come to GME for approval before submission to Medical Payroll.
It should be explained to the house staff member that all benefits/payroll deductions will be pulled from the salary supplement paid on the PAF.
Trainees are still eligible to contribute to their retirement accounts, but the percentage (and matching funds) are based solely on the PAF amount. No deductions can be taken from the Stipend.
The appointment as a Trainee must be in place throughout the period of time that the house staff is receiving T-32 or F-32 funding.
1. If grant funding begins or ends off-cycle, a change in the appointment must be requested. This can be in the form of an email from the Fellowship Director to Dr. Terhune, explaining the need for the change in appointment.
2. If grant funding crosses from one training year to another and the grant funding is not increased, the difference must be made up on the PAF to ensure that the salaries of the Trainees remain equal with those of the non-Trainees at the same level.
If you have any questions please contact Jennifer Lutgens at 2-4903 or [email protected].
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Payroll Process for Advancing, Transferring and Terminating House Staff
GME will provide instructions and due dates for house staff payroll actions during Program Coordinator Meetings and agendas each Winter/Spring. Pay close attention to the due dates and remember to allow time for any additional approvers required before GME approval. Any off-cycle actions are due to GME at least 5 days prior to payroll deadline to allow processing time. Remember that all paper pay forms (PAF/APF) must be submitted to GME for final processing. Do not submit any pay forms directly to medical payroll.
House Staff Advancing in the Same Program Advancement of most existing house staff is accomplished through the electronic personnel action changes (ePAC) online system (unless they are appointed as Trainees using the 9079 job code – require Paper PAFs). Training and resource information is available for the ePAC system at the link below. GME does not manage the technical/user aspects of ePAC. You may need to submit a Help Desk ticket if you are experiencing system problems.
• ePac – https://epacjpc.app.vumc.org/
Please make sure you use the appropriate job code (see below) and salary based on the PGY level for the next program year. If the advancing house staff will be paid from two or more sources please submit a earnings distributions change (EDC) to indicate the percent of salary paid from each center with an appropriate effective date.
House Staff Transferring to another GME Program or Faculty Position at VUMC A paper PAF will need to be submitted to GME reflecting the new home department, job code, salary, etc. In addition to the paper PAF, an earnings distribution change (EDC) must be initiated in ePAC for the appropriate cost centers to be charged.
Transfer Processing House Staff transferring from one VUMC program to another VUMC program (electronic & paper actions required)
• First Action – EDC (electronic distribution change) in ePAC o The program the house staff is currently appointed in will request the account/center number
to be charged from the new program o The current program will submit an EDC in ePAC o ALL EDC submissions are DUE BY JUNE 1st o The effective date will be the first day of the appointment in the new program o The EDC approval process must be completed BEFORE the paper PAF is submitted to medical
payroll • Second Action – Paper PAF (personnel action form / turnaround)
o The current program will initiate and sign the PAF o The current program will route the PAF to the new program for processing/signatures
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o The new program will submit the PAF to GME – DUE to GME BY JUNE 10th
ALL signatures must be in place before submitting the PAF to GME GME will HOLD the paper PAF until the EDC has been processed Once the EDC is processed, GME will submit the PAF to Medical Payroll Paper PAFs need to be submitted to medical payroll by the July payroll deadline (all EDC
approvals must be in place to allow for this) Submit PAFs to GME as early as possible. Do not hold them until the deadline.
o Medical Payroll will key ALL of the transfer information from the paper PAF (note this is ONLY for house staff – not regular staff)
Medical Payroll WILL NOT key the new charge account/centers from the paper PAF (EDC in ePAC required)
The charge account/center information must still be included on the paper PAF for confirmation (medical payroll will check against the processed EDC)
Additional ePAC actions for job code/salary/mail drop/home dept changes ARE NOT needed for house staff transfers (medical payroll will take this from the paper PAF)
Notes for VUMC House Staff transferring to VUMC Faculty The above process is the SAME for faculty transfers with the following allowance (if desired)
• When the new home department submits the paper PAF to GME as outlined above, they may request to be contacted to pick up the PAF for further signature processing
• If this is the case, the new department will submit the fully executed PAF to medical payroll o The new department must still hold the PAF until the EDC has been processed in ePAC o The same deadlines apply and the paper PAF must be submitted to medical payroll by the July
payroll deadline
All other advancement payroll actions will be processed as usual in ePAC: All ePAC actions DUE by JUNE 10th
• Job code changes
• Salary changes o Remember off-cycle house staff and those needing training extensions will need the July 1st
salary increase in ePAC before any advancement/termination actions are submitted • Terminations
o Effective date is the day after the last day of employment (i.e. appointment ends June 30th, termination will be effective July 1st)
House Staff Terminating and leaving VUMC An ePAC action must be submitted to terminate House Staff from Payroll. These actions should also be submitted for processing by June 10th to allow for GME and HR processing.
Job Codes The following job codes are used for residents and fellows appointed through GME. It is important to ensure use of the correct job code each time a payroll action is processed on paper or through ePAC.
Job codes: • 9011- Resident PGY-1 • 9012- Resident PGY-2
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• 9013- Resident PGY-3
• 9014- Resident PGY-4
• 9015- Resident PGY-5
• 9016- Resident PGY-6
• 9017- Resident PGY-7
• 9018- Resident PGY-8
• 9019- Resident PGY-9
• 9040- Chief Resident
• 9050- Resident in Research
• 9138- Clinical Fellow
• 9140- Clinical Fellow Trainees (VA Scholars)
• 9079- Resident or Fellow Trainee - NIH Training Grant
Which form do I use? GME is responsible for approving all house staff pay forms and ePAC actions because of the home department/center and/or job code. Please, make sure that you submit all paper personnel action forms (PAF) to the GME office for final signature approval. Do not submit them to Medical Payroll, as PAFs will be rejected by Medical Payroll (if the error is caught) for missing the GME PAF responsible person’s signature. GME also maintains copies of all pay forms submitted.
Use paper PAF: • New hires and rehires • Transfer between home departments
• Adding additional jobs
• Retroactive personnel actions
• Creation of new positions
• Activating an Inactive Position
• Changes to position distribution
• Benefit changes
• Any additional pay forms
• Any actions involving the 9079 job code (Trainees)
Use EPAC: • Position changes • Earnings distribution changes (EDC)
• Retroactive distribution changes (RDC)
• Position number changes within same home department
• All job code changes (unless involving 9079 job code - Trainees)
• Pay rate changes (unless involving 9079 job code – Trainees)
• Leave of absence requests (paid, unpaid, and return from leave)
• Standard Shift Changes
• Mail drop changes
• Reports to position changes
• Standard hours changes
• Terminations (unless involving 9079 job code – Trainees)
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Visiting Residents/Fellows
To be eligible for a visiting rotation at Vanderbilt University Medical Center, an applicant must be in an ACGME accredited training program.
For instructions for visiting residents/fellows, including the visiting resident/fellow application and the list of other required documentation, direct the person interested in a temporary rotation at Vanderbilt to the GME web site https://www.vumc.org/gme/13341.
The interested resident/fellow should submit the completed application and all supporting documents to you to check for completeness and for approval by your Program Director. Afterwards, the completed application and documentation must be submitted to the GME Office for final approval at least 90 days in advance of the desired rotation to allow for processing time. The complete Immunization Form must be submitted to the GME Office at least 30 days in advance of the rotation.
Please note that GME does not provide meal money, parking, etc. for visiting residents. If your department wishes to provide meal money for a visiting resident, contact [email protected] to coordinate.
Contracts for Visiting Residents/Fellows A contract is required for all visiting residents/fellows which requires a minimum of 90 days for processing in advance of the rotation start date. This is to ensure that all visiting house staff have the appropriate insurance coverage, workmen’s compensation, etc. A template has been developed by Legal Council to facilitate this process and can be used for visiting residents with a desired rotation of up to 6 months. If the visiting resident is included under a broader agreement an individual contract will not be necessary and we will continue to require the application and related documents 30 days in advance. If the rotation requested is longer than 6 months, a detailed contract will be required but the same process will apply. Please check with GME to clarify if you are uncertain regarding the need for an individual contract for a visiting resident. In addition to the application paperwork discussed in the above paragraph, the Program Coordinator or someone designated within the department will need to submit a request to Contracts Management (through the PEER system explained below) for a contract to be initiated and signed by designated officials at both institutions.
Submitting a Contract Request for Visiting Residents/Fellows PEER (Paperless Environment for Electronic Review) to Initiate Contract Development with Contracts Management: https://www.vumc.org/ocm/. Program Coordinators submit PEER Request for contract at least 90 days in advance.
• PEER Contract Submission Guide for Visiting Residents and Elective Away Rotations: https://gmeoffice.app.vumc.org/VisitingResidentApp
• PEER Checklist for Visiting Residents and Elective Away Rotations: https://www.vumc.org/gme/39438
• If the sending institution requires a PROGRAM LETTER OF AGREEMENT, attach it (signed or unsigned) in the PEER submission.
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Meal Money for Visiting Residents/Fellows Meal money for visiting residents/fellows can be purchased by the department, but is not required. To get meal money for a visiting resident, contact Thu Dang. An 1180 for the meal money amount is due to the GME office before the visiting resident’s start date.
Observerships/Externships
Vanderbilt University Medical Center cannot sponsor observerships or externships for international medical school graduates. There are multiple reasons for this including the following: malpractice insurance would not be provided; the individuals would be ineligible for a training license or exemption from licensure; and there are HIPAA rules that make even shadowing experiences too difficult to allow.
International medical students should apply through the School of Medicine Office of Students Records in the same manner as other visiting students (see https://medschool.vanderbilt.edu/explore-vusm/enrollment-services/).
For information on VUMC Observational Experience (for high school students, college students, etc.), visit: https://www.vumc.org/voe/
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Elective Away Rotations (Domestic and International)
The Office of Graduate Medical Education will consider Away Rotations for House Staff as approved by the Program Director as part of the educational training program. Advance planning is necessary for all the items that must be in place prior to an away rotation and Residents/Fellows should coordinate with the Program Director and Program Coordinator.
Two online systems are involved in the process: • GME Away Rotation Management System for U.S. & International Away Rotations: https://gme.app.vumc.org/gheportal/
o Residents/Fellows enter information in the System for on-line approval, information and
management of away rotations. o The GME Away Rotation Management System (ARMS) is integrated with the PEER system to
ensure a contract is developed, negotiated and signed by both institutions prior to final approval by the Associate Dean/DIO for GME. The Program Coordinator will need to enter the PEER request number or Contract number in the GME Away Rotation Management System.
See tutorial in GME ARMS (click on “Resources” ). o The GME Away Rotation Management System is integrated with Risk Management for approval
to ensure that insurance coverage is in place for the away rotation. o Residents/Fellows will be guided by information in the portal to obtain the appropriate medical
license, obtain appropriate immunizations, etc. • PEER (Paperless Environment for Electronic Review) to Initiate Contract Development with Contracts
Management: https://www.vumc.org/ocm/ o Program Coordinators submit PEER Request for contract at least 90 days in advance for
domestic away rotations or at least 120 days in advance for international away rotations. PEER Contract Submission Guide for Visiting Residents and Elective Away Rotations: https://gme.app.vumc.org/gheportal/ Attach these items in the PEER submission (or send to Contract Analyst assigned via
email after the PEER submission)
• PEER Checklist for Visiting Residents and Elective Away Rotations: https://gme.app.vumc.org/gheportal/
• PROGRAM LETTER OF AGREEMENT (not necessary to obtain signatures on PLA in advance - will be included with contract for signature)
The GME Away Rotation Management System is designed for house staff to manage their rotations away from Vanderbilt. The purpose of this site is to maintain a central repository of all approved rotation activities and to ensure house staff members are prepared for international or domestic away rotations. Once the House Staff Member enters and submits the desired rotation, the system will generate an email notification to the Program Director for on-line review and approval. The Program Coordinator will be copied on this notification.
It is the responsibility of the Program Coordinator to submit a PEER Request (minimum of 90 days in advance domestic/120 days in advance international) for a contract to be established unless one is already in place.
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The GME checklist and PLA (unsigned is okay) should be attached in the PEER submission. The PEER Request Number (generated when the PEER request is initiated) or Contract Number (if an existing contract is already in place) must be entered by the Coordinator into the GME Away Rotation Management System. This allows the systems to communicate with each other and will update the Global Health Education Portal on the status of the contract.
Risk Management will receive an email request for approval of the rotation through the Global Health Education Portal and approval will indicate coverage is being provided for the away rotation.
Final review and approval in the GME Away Rotation Management System will be generated by the Associate Dean for Graduate Medical Education/DIO once the contract is finalized. The Program Coordinator will receive an automatic email notification of this approval.
Please advise House Staff Members not to book airline flights or make other financial commitments related to away rotations until all items below are in place and confirmed. Please ensure that the House Staff Member has appropriate Medical Licensure for the location of the rotation before the rotation begins.
Domestic and International Elective Away Rotations require:
• Resident/Fellow to enter information into the GME Away Rotation Management System
• Program Director Approval in GME Away Rotation Management System (system email will be generated)
• Coordinator to submit PEER request for contract between Vanderbilt and Receiving Institution (request initiated by Program Coordinator 90 days (domestic)/120 days (international) in advance via PEER system. See links above to system and instructions.
• Program Letter of Agreement drafted by program to be included with contract for signature by receiving institution. (Scan as an attachment to PEER request or send to Contract Analyst assigned via email.)
• Program Coordinator enters PEER Request Number or Contract Number in the GME Away Rotation Management System. (Please make note of your PEER Request Number or Contract Number. An automated email from portal to coordinator will include link to portal with instructions.)
• Professional Liability Coverage (with PD approval in the GME Away Rotation Management System Risk Management will receive email to approve which will confirm coverage for the away rotation.)
• Authorization for Travel (within department – GME does not need this)
• Fully Executed Contract (signed by both institutions) and Associate Dean Approval to be in place before travel arrangements are made.
• Final approval in GME Away Rotation Management System by Associate Dean/DIO for Graduate Medical Education.
Exiting House Staff
Completion of Training Certificates Certificates are generated according to the completed advancements. A draft of “ready to print” certificates will be sent to the Program Coordinator via email to check for spelling of names, degree suffix and dates of
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training. If the resident/fellow has obtained any additional degrees the GME Office will need proof of these degrees (copy of diploma or transcript) to list the degree on the certificate. Once the email confirmation is received, certificates will be printed. An e-mail will be sent to the Program Coordinator requesting pick up of the certificates and instructions for signature routing. Certificates are first signed by Program Director, the Department Chair and the Dean of the School of Medicine before being returned to GME for final signature by Dr. Terhune, Associate Dean for GME. The Dean’s Office will contact GME to pick up the certificates. Once GME has received the certificates back with all signatures the Program Coordinator will be notified by email that the certificates have been signed by Dr. Terhune and are ready for pick-up. Certificates are released late June unless an earlier date is requested in advance and approved by Dr. Terhune.
Exit Process Several weeks in advance of a house staff termination date, the GME Office sends an e-mail to the exiting house staff and his/her Program Coordinator. Exit information is very important to GME for terminating House Staff for reporting to our funding sources. An electronic format is used for the Exit Form, while a hard copy is needed for the signature sheet. The signature sheet will need to be printed by the terminating House Staff member to circulate for signatures. There are two separate signature sheets, one for those terminating from GME but staying at Vanderbilt, and another for those leaving Vanderbilt. A link is included in the Exit Process email for changing of address with Human Resources so exiting House Staff will receive W-2 forms at the correct address prior to tax season. House staff should ensure that their EPIC inbox is cleared out before Medical Records will sign off on the individual exiting. You should contact Lisa King with any questions and/or problems regarding the exit process.
In the unusual circumstance where a member of the house staff leaves prior to the completion of training and does not go through the normal check-out process, the coordinator may be asked to collect the following items: ID Badge, Pager, Parking sticker/gate swipe key, scrubs, and other items assigned by the department. These items should be returned to the appropriate departments. Please notify GME that the above items have been collected/returned.
Please note the information under PAYROLL PROCESS for terminating house staff from payroll.
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Program Letters of Agreement (PLA)
The Program Letter of Agreement (formerly Memorandum of Understanding) is an ACGME requirement for resident/clinical fellow education at a participating site, which must be signed by the Program Director, the Signatory Authority at the Affiliate Institution and the DIO. The PLA addresses GME responsibilities between an individual accredited program and a site other than the sponsoring institution at which residents receive a required part of their education. This document, after it is signed, is in effect for a maximum of five years and must be renewed/resigned every five years with the affiliate institution so house staff may continue to participate in this part of the training process. The PLA should be renewed sooner than 5 years if there is a change in PD, DIO, or affiliate institution official who originally signed the PLA or if there is a significant change to the rotation or to ACGME policy which affects the rotation.
When is a PLA Required?
• ACGME requires a PLA between the program and each site to which house staff in that program are required to rotate.
• VUMC also requires a PLA between the program and each site to which house staff elect to rotate (ELECTIVE AWAY ROTATIONS)
Instructions for completing a Program Letter of Agreement
Template and Instructions–https://vanderbi.lt/gmepla
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Contracts between Institutions
Contracts or agreements between institutions may include broad affiliation agreements involving multiple programs (examples include St. Thomas, VA, etc.); affiliation agreements involving only one program where all residents participate in the rotation; military contracts (for residents supported by the US Navy, Army, Air Force, etc.); or agreements for residents participating in a VISITING ROTATION at Vanderbilt or Vanderbilt residents participating in an ELECTIVE AWAY ROTATION (required by Vanderbilt and GME policy). In any of the above circumstances, communication with GME is required.
When GME indicates a contract is necessary, the Program Coordinator should follow the PEER link (https://www.vumc.org/ocm/) to complete all necessary fields and submit to the Office of Contracts Management for set-up in our contracts database. You can find a PEER User Manual here (https://prd-medweb-cdn.s3.amazonaws.com/documents/gme/files/PEER%20Contract%20Submission%20Guide%20for%20GME%20Visiting%20ResidentAway%20Rotation%20Agreements.pdf).
You may also be contacted prior to expiration of a contract or agreement for information regarding the continuation of the agreement and any changes necessary for amendments.
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Compliance Requirements for House Staff
The GME Office tracks compliance items for house staff which are outlined in the House Staff Manual (https://prd-medweb-cdn.s3.amazonaws.com/documents/gme/files/HS%20Manual%20-%20FINAL.pdf) in the “Resuscitation Training & Documentation” and “Training Assignments and other Compliance Items” sections under “Conditions of Employment and Continued Employment.” GME occasionally will seek your assistance to ensure compliance of your house staff. You can check GME-tracked compliance items for your house staff in the Portal, under “Admin Dashboard”. Your department and/or division may have additional requirements for compliance which GME does not track.
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House Staff Manual
Policies and Other Information Regarding House Staff Most GME policies as well as some other information can be found in the House Staff Manual (https://prd- medweb-cdn.s3.amazonaws.com/documents/gme/files/HS%20Manual%20-%20FINAL.pdf), and are listed below. Use the interactive table of contents to quickly find what you need.
House Staff Information • Conditions of Employment and Continued Employment • Background Check and Disclosure Policy
• House Staff Stipends Policy
• Policy on Clinical and Education Work Hours
• Extracurricular Professional Activity (Moonlighting)
• Policy on External Residents/Fellows Visiting Vanderbilt
• Guidelines for House Staff Supervision
• Occupational Exposure Prevention Policy
• Training Program Reduction/Closure Policy
• Continuation of GME Support in the Event of a Disaster
• House Staff Called to Assist in the Event of a Disaster
• Certificate of Service
• Holiday/Vacation/Sick Time
• Leave Policy
• Resident/Fellow Eligibility and Selection
• Equal Employment and Affirmative Action/Anti-Harassment/Non-Discrimination/Anit-Retaliation
• Retaliation
• Compliance Program
• Conflict of Interest Policy/Vendor Interactions
• Policy on Resident Transfers
• Elective Away Rotations
• Benefits
• Support Services o Faculty/Staff Health & Wellness o Child and Family Center o Stress Management o Sleeping And Transportation Options For House Staff Too Fatigued To Return Home Safely o Fitness Facilities o Recognizing the Impaired Physician o House Staff Advisory Council
• GME Evaluation and Disciplinary Guidelines o Evaluation o Informal Counseling o Corrective Action
• House Staff Complaint/Grievance Procedures • General Information
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o Prescriptions/DEA o Eskind Biomedical Library o Long Distance Calls (V-Net) o Meal Money o White Coat Laundering o Sports o Free Tickets for Local Entertainment/Events o Discounts o Vanderbilt University Public Safety o Commodore Concierge o Personal Health and Wellbeing – New Patient Appointments o My Health at Vanderbilt
Medical Center Information • Professional Conduct Policy
• VUMC Computers and Clinical Applications
• Systems Access and Confidentiality
• Electronic Messaging of Individually Identifiable Patient and Other Sensitive Information
• Patient Photography and Video Imaging
• Video Policy For Simulation Training
• Social Media Policy
• Electronic Communications and Information Technology Resources
• False Claims Act and Whistleblower Protection
• Alcohol and Drug Use Policy
• News and Communications
• General Information o Admissions and Discharges o VUMC Quality Improvement Activities o Vanderbilt Home Care Services (VHCS) o Organ and Tissue Donation After Death
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Internal Reviews
Overview This IR is similar to a practice session for your next accreditation site visit and each institution follows different protocols for how these reviews are completed. This process is designed to help your program. The IR process determines how well you follow the program requirements, how you have responded to the citations and recommendations in your last accreditation letter and internal review, how satisfied your house staff are with the program, and many other topics.
The IR committee reviewing the program is composed of the DIO, an outside program director, and an outside program resident or fellow.
After review of your materials and interviews with the program director, faculty and house staff, the internal review committee makes recommendations for your program in a formal report. This report is internal and unavailable to your site visitor, but documentation of the date can be provided to the site visitor.
Procedure The following information provides guidelines to ensure timely compliance with program internal review procedures.
Megan Whitey will email the program director and coordinator no less than 90 days before the target date of the IR. The email will contain a scheduling request for the IR. The program must coordinate with Megan to find a date convenient to both Dr. Terhune and the program.
The program should ensure their ACGME ADS is up-to-date no later than two weeks before the date of the internal review so that the committee has time to review it and other materials GME will collect for the review.
The reviewed program’s attendees at the internal review must be:
• House staff (at least one peer-elected resident from each level). time required: 45 minutes
• Program Director and associate PD (if there is one) , Department Chair (if available) and Program Coordinator may participate as well. (PCs are especially encouraged to attend, but are not required.) time required: 45 minutes
• Program Faculty (of the Program Director’s choosing) time required: 30 minutes
The program must ensure that its representatives are present and on time.
Before the IR, the IR committee will review your most recent ADS information, your common program requirements, your most recent Annual Program Evaluation, ACGME resident and faculty surveys, New Innovations internal survey (completed by house staff), diversity report of current house staff, past year internal program evaluation and previous Internal Review packet. At the IR, they will interview the various program participants and discuss the materials with them.
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About a month after the IR committee meets with your program, you will receive a report documenting the observations and analysis of the IR committee. It will include helpful recommendations for improvement and may ask that you follow up with a progress report a few months later.
Special Reviews At any time GMEC may determine the need for (or the program, division, or department may request) a Special Review of a program. Special Reviews typically follow the same procedure as above, unless GMEC determines only a limited area of the program needs to be reviewed.
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Expansion and New Programs
House Staff Expansion Requests to Increase Size or Redistribute House Staff (Residents/Clinical Fellows), Proposals for New Clinical Fellowship Programs, and Applications for Non-ACGME Accredited Training Programs The expansion and proposal for new clinical fellowship programs and applications for non-ACGME accredited training program process is generally directed by Program Directors. Program Coordinators receive notification so they are in a position to assist with the process through their Program Director as requested.
The House Staff Expansion Committee functions as a subcommittee of the Graduate Medical Education Committee. Requests for expansion/new programs are generally called for twice a year, in January and July. An announcement, along with the appropriate forms needed for the requests, is sent out from the GME Office approximately six weeks prior to the committee meeting. The House Staff Expansion Committee reviews all requests (both the written forms as well as brief oral presentations from each requester) and makes recommendations for approval or denial to the Graduate Medical Education Committee based on the educational fortitude of the proposal. From there, the requests are reviewed by the Funds Flow Committee who review request from a financial standpoint and finally by Dr. Pinson. At this point the requester is issued a letter indicating approval or denial.
GME-Coordinated Meetings
Chief Residents Leadership Workshops/Chief Resident Retreat Educational seminars to assist current chief residents in understanding and performing the functions of their roles and Spring retreat for newly selected residents who will assume this role in July.
Graduate Medical Education Committee (GMEC) The Graduate Medical Education Committee meets monthly and reviews from an institutional perspective the implementation at Vanderbilt of the required “Institutional Requirements” of the ACGME. The Committee advises and monitors the Office of Graduate Medical Education, the Medical Center, and the Medical School of pertinent issues related to house staff (residents and clinical fellows) programs of the institution. Voting membership on the committee includes residents nominated by their peers. It also includes appropriate program directors, administrators, the accountable DIO, and may include other members of the faculty.
House Staff Advisory Council (HSAC) The Vanderbilt House Staff Advisory Council meets monthly and is composed of representatives from each clinical department. Matters of hospital policy that impact the house staff are discussed and information is disseminated through monthly minutes. Any issue pertaining to house staff experience can be referred to and discussed by the Council. Members of the Council serve as house staff representatives on most of the Standing Committees of the Hospital Medical Board as well as on House Staff Advisory Council committees. The Council annually sponsors the Vanderbilt University Medical Center Research Forum and selects the recipient of the Grant W. Liddle Award. HSAC on GME Office website: https://www.vumc.org/gme/2779
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House Staff Expansion Committee The House Staff Expansion Committee functions as a subcommittee of the Graduate Medical Education Committee. Members of the subcommittee are: Two members from the Department of Finance, two PDs and two residents from the GMEC, the GMEC chair, and the DIO.
Program Coordinator Meetings/Annual Retreat These meetings cover a variety of topics, chosen by the GME office and coordinators. All coordinators (ACGME and non-ACGME) are invited.
Program Director Meetings These meetings cover a variety of topics, chosen by the GME office and directors. All program directors (ACGME and non-ACGME) are invited. These are held quarterly.
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Forms/Documents and Online Tools
GME Website One of our goals is to make the GME website as helpful as possible to you. The forms and documents available on the GME website are located at https://www.vumc.org/gme/30502. Please email [email protected] if you have suggestions.
Other Online Tools
• GME Program Coordinator/Admin Portal: https://gme.app.vumc.org/GMEPortal/Login.aspx?ReturnUrl=%2fGMEPortal%2f
• ACGME Accreditation Data System (ADS): https://apps.acgme.org/connect/login?ReturnUrl=%252fconnect
• GME Track/FREIDA – AMA: https://services.aamc.org/gme/admin/login/index.cfm?fuseaction=login
• ERAS®: https://students-residents.aamc.org/
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Accreditation Council for Graduate Medical Education (ACGME) 1
Overview and Organization of ACGME
Mission and Scope
The Accreditation Council for Graduate Medical Education (ACGME) is a separately incorporated, non- governmental organization responsible for the accreditation of graduate medical education (GME) programs. Its mission is to improve healthcare and population health by assessing and advancing the quality of resident physicians’ education through accreditation. Its scope of accreditation extends to those institutions and programs in GME within the jurisdiction of the United States of America, its territories and possessions. International accreditation services are provided by a related entity, ACGME International LLC (ACGME-I). The ACGME's member organizations are the American Board of Medical Specialties, American Hospital Association, American Medical Association, Association of American Medical Colleges, and the Council of Medical Specialty Societies. Member organizations each nominate four members to the Board of Directors, which also includes two resident members, three public directors, the chair of the Council of Review Committees, one to four at-large directors, and a non-voting federal representative. To help you make sense of how ACGME runs, you can review the ACGME Policies and Procedures document here: http://www.acgme.org/acgmeweb/Portals/0/PDFs/ab_ACGMEPoliciesProcedures.pdf. It is not a document you will frequently use, but occasionally can be helpful for referencing accreditation procedures. The most helpful section is Accreditation Policies and Procedures and begins with section 15.00.
Review Committees
The ACGME has 29 review committees (one for each of the 27 specialties, one for a special one-year transitional-year general clinical program, and one for institutional review). The function of a Review Committee is to set accreditation standards and to provide peer evaluation of specialty and subspecialty residency programs (or, in the case of the Institutional Review Committee, to set accreditation standards and to provide peer evaluation of sponsoring institutions). The purpose of the evaluation is to assess whether the program or institution is in substantial compliance with the published set of ACGME educational standards, and to confer an accreditation status on programs and institutions. Each Review Committee is comprised of 6 to 15 volunteer physicians. Members of the Residency Review Committees (RRCs) are appointed by the AMA Council on Medical Education and the appropriate medical specialty boards and organizations. Members of the Institutional Review Committee and Transitional Year Committee are appointed by the ACGME Executive Committee and confirmed by the Board of Directors.
Expert Tip: Find Help with All Things ACGME If you find you need help regarding ACGME requirements, etc. beyond this manual and the ACGME webpage, remember that you are not alone! Besides asking your Program Director or the GME Office, remember that your fellow coordinators are one of your best resources. Reach out to a more experienced, mentor coordinator (email Jennifer Lutgens for an updated list). PCs with less than two years’ experience as a coordinator
1 Much of this section that follows was taken from www.acgme.org or from documents posted to www.acgme.org in May 2015. For the most up to date information about ACGME, visit their webpage.
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are also eligible to attend ACGME’s “Basics of Accreditation for New Program Coordinators Workshop”. Information on workshop dates is here: http://www.acgme.org/Meetings-and-Events/Workshops.
ACGME Requirements As you read through any ACGME requirements (or communications of any kind), it is helpful to know how ACGME defines each of the terms used. Their Glossary of Terms is a handy guide for this: http://www.acgme.org/Portals/0/PDFs/ab_ACGMEglossary.pdf?ver=2015-11-06-115749-460.
Institutional Requirements
Institutions sponsoring residency programs are expected to adhere to a set of Institutional Requirements. Kyla Terhune as VUMC’s Designated Institutional Official (DIO), VUMC’s CEO, and our Graduate Medical Education Committee (GMEC) are responsible for making sure VUMC meets these requirements, which are found here: http://www.acgme.org/Designated-Institutional-Officials/Institutional-Review-Committee/Institutional- Application-and-Requirements. One part of the institutional requirements that you might hear about is the ACGME CLER Visit.
Clinical Learning Environment Review (CLER) The ACGME has established the CLER program to assess the graduate medical education (GME) learning environment of each sponsoring institution and its participating sites. CLER emphasizes the responsibility of the sponsoring institution for the quality and safety of the environment for learning and patient care. ACGME will notify the sponsoring institution’s DIO of the CLER Site Visit Team’s arrival date and expected length of visit no less than 10 days prior to the visit. We expect VUMC will have a CLER visit once in roughly every 24 months. Program coordinators aren’t directly involved in CLER visits, but you might be aware of or assist with the GME Office’s coordination of meetings, etc. that involve your house staff, program director(s), and faculty. More information is found here: http://www.acgme.org/What-We-Do/Initiatives/Clinical-Learning- Environment-Review-CLER.
Common Program Requirements
Common program requirements (CPR) are requirements that all programs, regardless of specialty, must meet. These requirements are likely incorporated into the same document as your specialty or subspecialty specific program requirements, but you can view them separately, along with some FAQs here: http://acgme.org/What-We-Do/Accreditation/Common-Program-Requirements.
Program Evaluation Committee (PEC) and Annual Program Evaluation (APE) One part of the common program requirements is having a Program Evaluation Committee (PEC) which is composed of at least two program faculty members and at least one resident, has a written description of its responsibilities, and participates actively in planning, developing, implementing, and evaluating educational activities of the program; reviewing and making recommendations for revision of curriculum goals and objectives; addressing areas of non-compliance with ACGME standards; and, reviewing the program annually using evaluations of faculty, residents, and others. Through the PEC, the program is responsible for rendering a written Annual Program Evaluation which should include:
• resident performance
• faculty development
• graduate performance
• program quality
• progress on the previous year’s action plan(s)
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The PEC must prepare a written plan of action to document initiatives to improve performance in one or more of the areas listed above as well as delineate how they will be measured and monitored. The action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes.
Specialty and Subspecialty Specific Program Requirements
Programs must also demonstrate substantial compliance with requirements established by the Review Committee (RC) for their specialty to be accredited. Each Review Committee has specialty and subspecialty specific program requirements, which can be found by following the links for the appropriate specialty under the “Specialties” tab here: http://www.acgme.org/ . That will take you to your Review Committee’s page which contains links to the specialty’s program requirements and all subspecialties’ program requirements. There are also FAQs, milestones, names and contact information for your RC’s staff, RC agenda closing and meeting dates and other resources.
Program Accreditation ACGME extensively uses the Accreditation Data System (ADS) to manage accreditation data for all programs. Some of this data is publicly available on the public version of ADS (https://apps.acgme.org/ads/public/), while detailed accreditation data is submitted, communicated, and stored behind password protection here: https://www.acgme.org/ads. Your Program Director can give to access by adding you to the program. Once he/she logs into ADS, he/she can go to the program leadership section under the profile tab and then click “Add Personnel”.
Initial Accreditation
Once a new program has gone through the process for EXPANSION AND NEW PROGRAMS, or concurrently with that process, you might be assisting the new Program Director in applying for ACGME accreditation.
Application for Initial Accreditation Instructions for applying for Initial Accreditation are here: http://www.acgme.org/acgmeweb/Portals/0/ApplicationInstructions.pdf. FAQs about new program applications are here: http://acgme.org/acgmeweb/Portals/0/PDFs/fs_faq.pdf. The application will be completed in the Accreditation Data System (ADS) and must be initiated by Dr. Kyla Terhune as the DIO, but to prepare, you can view a Word version of the application by locating it on your specialty page. Further guidance for completing the application is available in ADS once the application is initiated. Before the Program Director submits (or has you submit) the application in ADS, it is recommended to print it and have others review for completion, accuracy, spelling errors, etc. Please note that Initial Accreditation fees are the responsibility of the department. Afterwards, GME will pay the annual accreditation fee.
Site Visit Most subspecialty programs do not require a site visit from ACGME as part of the application process, but if the new program is a core program (not a subspecialty) or if the program was previously accredited and is re- applying for accreditation, a full site visit will be required. All programs, however, do require a full site visit at the conclusion of their two-year initial accreditation period. Programs are given a minimum of 30 days of advance notice (by way of an e-mail and a simultaneously posted detailed site visit announcement letter in the program’s folder in ADS). Programs should review the letter
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carefully; it will contain detailed instructions for how and when to update the information in ADS, and any specific instructions for the particular program. More information about site visits is found here: http://www.acgme.org/acgmeweb/tabid/228/GraduateMedicalEducation/SiteVisitandFieldStaff/SiteVisitFAQ. aspx. The Designated Institutional Official (DIO) will want to review all information and documentation you are planning to submit for your site visit at least two weeks prior to the due date for submission to ACGME. Dr. Kyla Terhune in the GME Office is our DIO. The DIO will probably require revisions or have questions following the initial review. The DIO will let you know when your materials can be considered complete and ready for submission. Be sure to follow the ACGME submission instructions exactly.
Continued Accreditation
RRC Annual Data Review All programs will be reviewed annually by the relevant Review Committee. The Review Committee will confer an accreditation decision of Continued Accreditation based on satisfactory ongoing performance of the program. When a program’s performance is deemed unsatisfactory, or when performance parameters are unclear, the Review Committee may change the program’s accreditation status or request a site visit and/or additional information prior to rendering a decision. The Residency Review Committee may use the following information to assess programs (not all are applicable to every program or every year):
• ADS annual update
• Resident Survey
• Faculty Survey
• Milestone data
• Certification examination performance
• Case Log data
• Hospital accreditation data
• Faculty and resident scholarly activity and productivity
• ACGME Complaints (Complaints submitted to ACGME by an individual or group regarding issues related to compliance with accreditation standards)
• Verified public information
• Historical accreditation decisions/citations
• Institutional quality and safety metrics
• Other Following the RRC’s review, a Letter of Notification is issued to the program. The PD gets an e-mail that the letter has been posted to ADS. For help interpreting the letter see the Key to Standard Letter of Notification for Continued Accreditation here: http://www.acgme.org/acgmeweb/Portals/0/KeyStandard.pdf.
Accreditation Data System (ADS) Accreditation Data System (ADS) is a web-based system that contains critical accreditation data for all sponsoring institutions and programs. ADS serves as an ongoing communication tool with programs and sponsoring institutions, as well as Residency Review Committee staff. ADS incorporates several ACGME applications and functions. Program Directors are responsible for annually verifying/updating critical accreditation program information (including case logs for some specialties) and keeping resident records current. Typically PDs will have their Program Coordinator verify and update ADS; the PD should then review all information for accuracy and approval. Before the PD submits (or has you submit) an update in ADS, it is recommended to print and have others review for completion, accuracy, spelling errors, etc.
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Aside from the annual update, any changes should be reflected in ADS as they occur. A best practice is to check ADS frequently to make sure it is always up to date. Link to ADS is here: http://www.acgme.org/acgmeweb/tabid/159/DataCollectionSystems/AccreditationDataSystem.aspx.
Expert Tip: Verifying Board Certification of Faculty You can verify a physician’s American Board of Medical Specialties (ABMS) certification by selecting the appropriate member board in the QUICK REFERENCE WEB LINKS. Once on the member board’s website, look for a link that says something like “Check a Certification” or “Verify a Certification.” If the member board does not have this option you can use ABMS’s Certification Matters website, which requires a free registration: http://www.certificationmatters.org/. This can be a helpful tool in completing the Faculty portion of ADS.
Annual Resident/Fellow, and Faculty Surveys The ACGME’s Resident/Fellow and Faculty Surveys are used to monitor graduate medical clinical education and provide early warning of potential non-compliance with ACGME accreditation standards. All specialty and subspecialty programs (regardless of size) will be required to participate in these surveys each academic year between the months of January and June. When programs meet the required compliance rates for each survey, reports are provided that aggregate their survey data to provide an anonymous and comparative look at how that program compares against national, institutional, and specialty averages. Samples of these surveys are not available, but the questions will pertain to these general content areas: Clinical Experience and Education, Faculty, Evaluation, Education Content, Resources, Patient Safety, and Teamwork. More information (including FAQs) and instructions for residents/fellows and faculty to access the surveys is found here: http://www.acgme.org/acgmeweb/tabid/97/DataCollectionSystems/ResidentFellowSurvey.aspx.
Milestones and the Clinical Competency Committee (CCC) For accreditation purposes, the Milestones are competency-based developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. More information is here: http://www.acgme.org/What-We-Do/Accreditation/Milestones/Overview. Use the “Milestones by Specialty” button to find your specialty’s milestones. In order to evaluate resident and fellow progress within the milestones, each program uses a Clinical Competency Committee (CCC), comprising three or more members of the active teaching faculty. ACGME provides a CCC Guidebook here: http://www.acgme.org/acgmeweb/Portals/0/ACGMEClinicalCompetencyCommitteeGuidebook.pdf.
Case Logs Your RRC may require your program’s residents/fellows to use ACGME’s Resident Case Log system to document experiences to meet minimum educational requirements as outlined in your Program Requirements. Other programs use the system, but are not required to do so. Review your Program Requirements to determine whether your program is required to use the system. The Case Log system login for residents/fellows is here: http://www.acgme.org/acgmeweb/tabid/161/DataCollectionSystems/ResidentCaseLogSystem.aspx.
Site Visits All ACGME site visits are either Focused or Full site visits. Below is some information about these two types of site visits that occur for established programs. More information about site visits is found here:
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http://www.acgme.org/acgmeweb/tabid/228/GraduateMedicalEducation/SiteVisitandFieldStaff/SiteVisitFAQ. aspx.
Focused Site Visit The ACGME uses Focused visits: (1) to conduct a timely, in-depth explorations of potential problems arising out of a Review Committee’s review of annually-submitted accreditation data; and (2) to assess the merits of a complaint or for other circumstances as requested by a specific Review Committee.
Full Site Visit The ACGME uses Full visits for established programs for one of three reasons: (1) to address broad concerns identified during the review of data submitted to the ACGME annually; (2) to assess the merits of a complaint or for other circumstances as requested by a specific Review Committee; and (3) to assess overall compliance and ongoing improvement in a program during the scheduled 10-year site visit.
10-Year Self-Study and Site Visit Every ten years of continuous accreditation, all programs are required to complete the self-study summary, 12 to 18 months before a site visit. The site visit announcement letter will contain specific instructions. To see the approximate date for your next 10-year self-study and site visit, you can look in ADS, or search for your program here (the public version of ADS): https://apps.acgme.org/ads/Public/. The approximate date will be listed under “Accreditation and General Information”.
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Documentation/Forms for ACGME Programs
Coordinators should be familiar with the documentation that is required for the program and each resident/fellow and work closely with the PD to ensure that all documentation is up to date and available as needed. Information that follows is a guideline and can be used as a basic structure on which to base your program documentation. Please reference the ACGME website for changes/updates, refer to your Program Requirements, and consult your PD.
• Overall educational goals for the program
• Competency-based goals and objectives for each experience at each educational level
• Policy on supervision of residents/fellows
• Policy and procedure for resident/fellow duty hours and work environment
• Moonlighting policy
• Evaluations o Formative evaluations of residents (at completion of each rotation) o Evaluations showing multiple evaluators (faculty, peers, etc.) o Documentation of competency-based semi-annual evaluations with feedback o Final summative evaluation (graduating residents) o Annual written confidential evaluations of faculty by residents o Annual written confidential evaluations of program by residents o Annual written evaluations of program by faculty
• Documentation of program evaluation (i.e., minutes from meeting) and written improvement plan • Your program may refer to this as the Resident Education Committee
• Documentation of resident/fellow duty hours (whether using an electronic system or on Duty Hours Form)
• Resident/fellow files – current and most recent graduates. Resident files should contain the following information; however, the following is what is required by ACGME – you will also want to keep any personnel-related documentation in resident files as well
o Written evaluations from faculty and others o Periodic evaluations (every 6 months, at a minimum) by Program Director or designee or
resident evaluation committee o Records of resident rotations and other training experience, including surgical and procedural
training as applicable o Records of disciplinary actions, as pertinent o For residents engaged in moonlighting, a prospective, written statement from program director o Signed resident/fellow contract o Documentation of prerequisite education and/or training, ECFMG certificate if graduate of a
medical school outside the US and Canada o Resident diploma o Material required by ACGME institutional and specialty program requirements o Other content as determined by program director and/or sponsoring institution
• Files of residents/fellows transferred into program with documentation of previous experience and summative competency-based performance evaluations (if applicable)
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Additional documentation we are required by the ACGME to keep: • Case and procedure logs (per specialty program requirements)
• Documentation of presentations/education on fatigue and impaired physician
• Conference schedules
• Documentation of conference attendance
• Faculty and resident on-call schedules
• Due process/grievance policy
• Program-specific policy on eligibility/selection
• Program-specific policy on promotion
• Policy on non-teaching patients (per specialty program requirements)
• Lines of responsibility policy
• Documentation of active competency-based performance improvement
• Master Affiliation Agreements
• Current program letter(s) of agreement (PLA)
• Documentation of internal review
• Institutional policies o GME disaster policy o Conflict of interest policy/policy on vendor relationships o Policy of accommodation for residents with disabilities
• ACGME survey results and GME institutional survey results
Examples of additional necessary general information: • Specialty-specific documentation
• Leave Requests
• Travel/Reimbursement Forms
• Advancement forms
• Payroll action forms (originals for new residents/turnarounds from GME on returning residents)
• Exit Forms
The GME Office provides access to New Innovations which is a residency management software to assist in the management of information. Documentation may also be maintained in resident/fellow files, binders, etc., based on the program preference. Regarding program policies, it is recommended that a link to the House Staff Manual be used to reference policies instead of including the actual policy text to avoid the need for updates each time the House Staff Manual is revised.
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ACGME Site Visit Preparation
Below is a list of documents a site visitor may want to look at during a site visit and may be helpful to review in advance of a site visit. Please note that this is not a complete listing of all items the site visitor may want to see!
• Policies (be prepared to show how they are distributed)
o Supervision of residents (program and institution) o Policies and procedures for resident duty hours and work environment (Resident Health and
Wellness) (program and institution) Duty hours Fatigue and stress
o Moonlighting (program and institution) o Selection and promotion of residents (program and institution) o Program policy manual (can be online) o Institutional policy manual (House Staff Manual)
Formal Grievance Procedure (program and institution) • Goals/Objectives
o Program Educational Goals o Competency-based goals & objectives for each rotation at each level
• Program Letters of Agreement (PLAs) • Resident Files
o Documentation of Training for Transfer residents o Current residents and most recent program graduates (2 to 3 samples in upper years of
program if a large program) • Evaluations
o For each rotation o Completed evaluations of residents from their files o Showing use of multiple evaluators, 360 (peers, faculty, patients, self, other professional staff) o Documentation of semiannual evaluations of performance with feedback o Final (summative) evaluations of residents documenting performance during the final period of
education and verifying that the resident has demonstrated sufficient competence to enter practice without direct supervision
o Completed annual written confidential evaluations of faculty by residents o Completed annual written confidential evaluations of program by the residents o Evaluations of rotations by residents o Completed annual written confidential evaluations of program by the faculty o Documentation of Annual Evaluation of Faculty by Program (PD or committee) o Documentation of program evaluation and written improvement plan
• Documentation of Duty hours
• Completed procedure/case logs—how data accuracy is verified
• Didactic Conference schedule for the current academic year
• Didactic Attendance Records
• Documentation of Institutional Quality Assurance Instruction
• Sample of Institutional House Staff Agreement (contract)
• Documentation of Informing Residents/Candidates of Program Length
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• Minutes of Resident Advisory/Education Committee meetings and any additional faculty meetings including discussion of the program and training issues.
The site visitor might ask questions similar to the following:
1. What changes have been made in the program since the last site visit? 2. Are all of your faculty board certified in the specialty they teach in? If not, why not? 3. Do you feel as though you get the support you need from department? 4. Do the house staff have a designated office? Who do they share their office with? 5. Where did your fellows do residency training? Or where did your residents do their internship/go to
medical school? 6. How often are the board exams administered for your specialty? 7. Do you have a set interval evaluation period? 8. Are your rotation evaluations in New Innovations? 9. What innovative projects are house staff involved in? 10. What are the goals and objectives for a research rotation (if there is one)? 11. Do your house staff publish a paper during their tenure? 12. Do your fellows and residents attend trainings and/or meetings? 13. Do other people rotate through the service that the house staff are on? How does this affect the house
staff learning? 14. Tell me about the depth and breadth of cases the house staff see. 15. What are the house staff that leave the program doing? 16. What is your board pass rate? 17. Do you do 360 evaluations where various staff have the opportunity to evaluate the house staff? 18. Do your house staff moonlight? 19. What language is used in the final summative evaluation to express that the house staff is competent
to practice independently? 20. Is there anything else that you would like to share or that you think I don't understand about your
program? 21. What faculty development is available? (Institution and Program Level) 22. In what area(s) have you seen your program grow/weaken? 23. Where does your leadership provide the greatest amount of resources? 24. Questions about the Annual Program Evaluation (the site visitor will not have a copy of this, but is
looking for faculty, residents, and chair to have an understanding of what is included in the document.
Progress Documentation for Each Resident
Academic Progress Portfolios • CHRONOLOGICAL PROGRESS DOCUMENTATION by PGY Level to include:
o Mentor Reports o Learning Plans o Remediation Plans o Remediation Testing o Probation/Warning Letters o Counseling Notes o Semi-Annual PD Reports
• 360 EVALUATIONS to include: o Faculty of Resident by rotation
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o Nursing of Resident done quarterly o Patient of Resident done regularly during clinics o Peer evaluations done semi-annually o Self-evaluations done semi-annually o Student of Resident done at end of each block o Continuity Clinic evaluations done quarterly
• IN-SERVICE EXAMS to include o CREOG’s Exam Results o USMLE Test Results o COMLEX Test Results o ITE Results (In-Training Exam)
• PROBLEMS to include o Evaluation low scores o Complaints o Incident reports o Deficiency reports
• SCHOLARLY ACTIVITY to include o Presentation documentation and evaluations o Research documentation o Conferences o Publications
• TESTING to include o Lecture Quizzes o Rotation Tests o LLL Tests o Simulation Evaluations o Misc. Testing
• CORE COMPETENCY DOCUMENTATION to include: o Documentation of completion of any core competency learning module o Print outs from E*Value by Core Competency showing progress throughout training
• STATISTICS DOCUMENTATION to include o Print outs from Op-Log
Skill Progress Portfolios • FACS CARDS for each procedure type • H&P CHART REVIEWS AND PROGRESS SUMMARIES
• GOALS AND OBJECTIVES from each rotation
• SURGICAL CURRICULUM Documentation
Administrative Portfolios • APPLICATION (Original ERAS® App or VUMC application) • PRE-REQUISITE EDUCATION/TRAINING (Med School Diploma, Residency Certificates)
• CERTIFICATIONS (ACLS/BLS/PALS Card, licensure, etc.)
• CONFIDENTIAL/LEGAL
• CONTRACTS & EMPLOYMENT INFO
• DUTY HOUR DOCUMENTATION
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Administrative Documentation Binders Some coordinators suggest having a binder for each Academic Year, for each category below, going back as far as the last site visit. Regardless of how your program documents these activities, ensure the records are maintained in a complete and accurate manner.
• ANNUAL PROGRAM EVALUATION AND REVIEW to include
o All documentation presented and reviewed at the Annual Program Evaluation Review Agendas Minutes including attendees Review/report of yearly residents goals and objectives, curriculum issues, examination
status, case logs, etc. Supporting documentation of issues discussed and materials provided
• DUTY HOURS to include o Monthly print outs documenting that duty hours were checked and are compliant
• EDUCATION COMMITTEE MEETINGS to include o Agendas o Minutes including attendees o Report of ongoing resident education issues, objectives, and curriculum o Supporting documentation of issues discussed and materials provided
• FACULTY MEETINGS (if applicable) to include o Minutes of monthly faculty meetings, with Education/Resident issues highlighted for
documenting that all required residency items are discussed with the faculty, yearly • GME MEETINGS to include
o Minutes and hand-outs from institutional GME Meetings (Coordinator Meetings, PD Meetings, GMEC, etc.)
• GRAND ROUNDS /TEACHING ROUNDS to include o Attendance list/Sign-In Sheets o Flyer containing topic and presenter info o Summary of completed evaluation forms
• JOURNAL CLUB/RESEARCH FORUM to include o Attendance list/Sign-In Sheets o Flyer/Pamphlet containing topic and presenter info o Copy of article and/or Power Point print-out o Completed Evaluation Forms
• DIDACTICS/LECTURES to include o Attendance list/Sign-In Sheets o Lecture Schedule
• PRE-OP CONFERENCE o Sign-In Sheets o Copy of Case Reports presented
• RESIDENCY MANUAL to include o All residency policies o Curriculum
• RESIDENT MEETINGS (if applicable) to include o Agendas for monthly meetings o Minutes for monthly meetings
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o Supporting documentation from monthly meetings • PREVIOUS SITE VISITS to include
o PIF o Letters of Accreditation from each site visit o Citation Response letters o Supporting documentation for information in the PIF (stats, etc.)
• STATISTIC ENTRY (if applicable) o Copies from OP-Log Weekly that documents who was/wasn’t compliant with timely entry
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Quick Reference Web Links
Accreditation Council for Graduate Medical Education (ACGME) www.acgme.org
Association for Hospital Medical Education (AHME) www.ahme.org
American Medical Association (AMA) www.ama-assn.org
Association of American Medical Colleges (AAMC) www.aamc.org
Education Council for Foreign Medical Graduates (ECFMG) www.ecfmg.org
GME Track-Resident Tracking System www.aamc.org/gmetrack
National Residency Match Program (NRMP) www.aamc.org/nrmp
Training Administrators of Graduate Medical Education (TAGME) National Board for Certification www.tagme.org
Vanderbilt Office of GME https://www.vumc.org/gme/
Specialty Board Web site
Allergy and Immunology www.abai.org
Anesthesiology www.theaba.org
Colon and Rectal Surgery www.abcrs.org
Dermatology www.abderm.org
Emergency Medicine www.abem.org
Family Medicine www.theabfm.org
Internal Medicine www.abim.org
Medical Genetics and Genomics www.abmgg.org
Neurological Surgery www.abns.org
Nuclear Medicine www.abnm.org
Obstetrics and Gynecology www.abog.org
Ophthalmology www.abop.org
Orthopaedic Surgery www.abos.org
Otolaryngology www.aboto.org
Pathology www.abpath.org
Pediatrics www.abp.org
Physical Medicine and Rehabilitation www.abpmr.org
Plastic Surgery www.abplsurg.org
Preventive Medicine www.theabpm.org
Psychiatry and Neurology www.abpn.com
Radiology www.theabr.org
Surgery www.absurgery.org
Thoracic Surgery www.abts.org
Urology www.abu.org
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Quick Phone/Contact Guide
For these or other VU and VUMC numbers, you can also go to the online directory (https://peoplefinder.app.vumc.org/).
VUMC Phone Use: To dial on campus phones (excluding VA) use last five digits of number
VUMC to VA communication: Calling VAMC: Dial 9-615-327-4751; if you know the extension, dial 9-615-873- (4 digit extension).
• Office of Graduate Medical Education
• Emergency Services
• Admitting (VCH)
615-322-4916
911 (615-421-1911 from a cell)
615-936-4338
• Admitting (VUH)
615-343-0179
• Center for Professional Health
615-936-0678
• Federal False Claims Act Reporting hotline
800-424-5197
• Emergency Registration (VCH)
615-343-27663
• Emergency Registration (VUH)
615-322-3391
• Eskind Biomedical Library
615-936-1410
• First Report of Work Injury https://veritas.app.vumc.org/
• Music City Taxi Company
615- 865-4100
• Occupational Health Clinic
615-936-0955
• Office of Legal Affairs – Medical Center
615-936-0323
• News and Communications
615-322-4747
• Employee Relations
615-343-4759
• Patient Relations
615-322-6154
• Faculty and Staff Health and Wellness
615-936-0961
• Pharmacy (Central)
615-322-0703
• Pharmacy (OHO)
615-322-2688
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• Pharmacy (MCE) 615-936-1040
• Pharmacy (TVC Outpatient)
615-322-6480
• Pharmacy (VCH)
615-322-0708
• Pharmacy (VCH Outpatient)
615-936-6337
• Risk and Insurance Management
615-936-0660
• Tennessee Donor Service
888-234-4440
• Vanderbilt Environmental Health & Safety
615-322-2057
• Vanderbilt University Public Safety
615-322-2745
• VUPS Emergency
615-421-1911
• VUPS Walking Escorts
615-322-2745
• Vanderbilt Home Care
615-936-0336
• Work/Life Connections-EAP
615-936-1327
Common Acronyms/Abbreviations Used in GME
AAMC Association of American Medical Colleges
ABMS American Board of Medical Specialties ACCME Accreditation Council for Continuing Medical Education
ACGME Accreditation Council for Graduate Medical Education
ADS Accreditation Data System
AHA American Hospital Association
AHME Association for Hospital Medical Education
AMA American Medical Association
AMA-CME American Medical Association – Council on Medical Education
CAAR Computer Assisted Accreditation Review
CBE Competency-Based Education CCC Clinical Competency Committee
CLER Clinical Learning Environment Review
CMS Centers for Medicare and Medicaid Services
CMSS Council of Medical Specialty Societies
CRCC Council of Review Committee Chairs
CRCR Council of Review Committee Residents
DIO Designated Institutional Official
ECFMG Educational Commission for Foreign Medical Graduates
ERAS® Electronic Residency Application Service FREIDA Fellowship and Residency Interactive Database (AMA)
FS Accreditation Field Staff
FSMB Federation of State Medical Boards
GME Graduate Medical Education
HIPAA Health Insurance Portability and Accountability Act
IRC Institutional Review Committee
IRD Institutional Review Document
JC (formerly JCAHO) Joint Commission on Accreditation of Healthcare Organizations
LCME Liaison Committee on Medical Education NBME National Board of Medical Examiners
NRMP National Resident Matching Program PC Program Coordinator
PD Program Director
PGY Post Graduate Year
PLA Program Letter of Agreement
RC or RRC Review Committee or Residency Review Committee
RQ Resident Questionnaire (used in Internal Medicine)
SV Site Visitor
SSV Specialist Site Visitor
TAGME Training Administrators in Graduate Medical Education TYRC Transitional Year Review Committee
USMLE United States Medical Licensing Examination
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Glossary of Terms Most of this glossary is taken from ACGME’s Glossary of Terms found here: http://www.acgme.org/Portals/0/PDFs/ab_ACGMEglossary.pdf?ver=2015-11-06-115749-460. Reference the Glossary at the above web address for the most up to date information.
Academic Appointment An appointment to a faculty category (e.g. professor, Associate Professor, Adjunct Clinical Instructor, etc.) of a degree-granting (e.g. BS, BA, MA, MD, DO, PhD, etc.) school, college, or university.
Accreditation Council for Graduate Medical Education (ACGME) The ACGME is responsible for the accreditation of post-graduate medical training programs within the United States. Accreditation is accomplished through a peer review process, and is based upon established standards and guidelines.
ACLS Advanced Cardiac Life Support
Accreditation A voluntary process of evaluation and review based on published standards and following a prescribed process, performed by a non-governmental agency of peers.
Accreditation Data System (ADS) The Web ADS is an online service of ACGME that allows authorized program directors of accredited graduated medical education programs to input limited amounts of Program Information data to servers maintained by the ACGME or on its behalf.
Applicant An M.D. or D.O. invited to interview with a GME program.
Assessment An ongoing process of gathering and interpreting information about a learner’s knowledge, skills, and/or behavior.
At-Home Call Same as Pager Call. A call taken from outside the assigned site. Time in the hospital, exclusive of travel time, counts against the 80 hour per week limit but does not restart the clock for time off between scheduled in-house duty periods. At-Home Call may not be scheduled on the resident’s one free day per week (averaged over four weeks).
BLS Basic Life Support
Categorical Resident Also see “Graduate Year 1". A resident who enters a program with the objective of completing the entire program.
Certification A process to provide assurance to the public that a certified medical specialist has successfully completed an approved educational program and an evaluation, including an examination process designed to assess the knowledge, experience and skills requisite to the provision of high quality care in a particular specialty.
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Chief Resident Typically, a position in the final year of the residency (e.g., surgery) or in the year after the residency is completed (e.g., internal medicine and pediatrics).
Citation A finding of a Review Committee that a program or an institution is failing to comply substantially with a particular accreditation standard or ACGME policy or procedure.
Clarifying Information A Review Committee may request clarifying information that specifies information to be provided, including a due date for the clarifying information.
Clinical Refers to the practice of medicine in which physicians assess patients (in person or virtually) or populations in order to diagnose, treat, and prevent disease using their expert judgment. It also refers to physicians who contribute to the care of patients by providing clinical decision support and information systems, laboratory, imaging, or related studies.
Clinical Competency Committee A required body comprising three or more members of the active teaching faculty who is advisory to the program director and reviews the progress of all residents in the program.
Clinical Learning Environment Review (CLER) The ACGME Clinical Learning Environment Review (CLER) provides the profession and the public a broad view of sponsoring institution’s initiatives to enhance the safety of the learning environment and to determine how residents are engaged in the patient safety and quality improvement activities.
Clinical Responsibility/Workload Limits Reasonable maximum levels of assigned work for residents/fellows consistent with ensuring both patient safety and a quality educational experience. Such workloads, and their levels of intensity, are specialty-specific and must be thoroughly examined by the RRCs before inclusion in their respective program requirements.
Clinical Supervision A required faculty activity involving the oversight and direction of patient care activities that are provided by residents/fellows.
Combined Specialty Programs Programs recognized by two or more separate specialty boards to provide GME in a particular combined specialty. Each combined specialty program is made up of two or three programs, accredited separately by the ACGME at the same institution.
Common Program Requirements The set of ACGME requirements that apply to all specialties and subspecialties.
Competencies Specific knowledge, skills, behaviors and attitudes and the appropriate educational experiences required of residents to complete GME programs. These include patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.
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Complement The maximum number of residents or fellows approved by a Residency Review Committee per year and/or per program based upon availability of adequate resources.
Compliance A program’s or institution’s adherence to a set of prescribed requirements.
Conditional independence Graded, progressive responsibility for patient care with defined oversight.
Confidential Information intended to be disclosed only to an authorized person; that an evaluation is deemed confidential does not imply that the source of the evaluation is anonymous.
Consortium An association of two or more organizations, hospitals, or institutions that have come together to pursue common objectives (e.g., GME).
Continued Accreditation A status of “Continued Accreditation” is conferred when a Review Committee determines that a program or sponsoring institution has demonstrated substantial compliance with the requirements.
Continuity clinic Setting for a longitudinal experience in which residents develop a continuous, long-term therapeutic relationship with a panel of patients.
Continuous time on duty The period that a resident or fellow is in the hospital (or other clinical care setting) continuously, counting the resident’s (or fellow’s) regular scheduled day, time on call, and the hours a resident (or fellow) remains on duty after the end of the on-call period to transfer the care of patients and for didactic activities.
Core Program See SPECIALTY PROGRAM.
Designated Institutional Official (DIO) The individual in a sponsoring institution who has the authority and responsibility for all of the ACGME- accredited GME programs.
Didactic A kind of systematic instruction by means of planned learning experiences, such as conferences or grand rounds.
Disaster An event or set of events causing significant alteration to the residency/fellowship experience at one or more residency/fellowship programs.
Duty Hours Duty hours are defined as all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent on in-house call, and other scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.
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ECFMG Educational Commission for Foreign Medical Graduates
ECFMG Number The identification number assigned by the Educational Commission for Foreign Medical Graduates (ECFMG) to each international medical graduate physician who receives a certification from ECFMG.
Elective An educational experience approved for inclusion in the program curriculum and selected by the resident in consultation with the program director.
ERAS® Electronic Residency Application Service. ERAS® is most commonly used by medical graduates or medical students in their final year of medical school to apply for specialized graduate training in ACGME-accredited residency programs in the US. Many residency and fellowship programs require applicants to apply through ERAS®. ERAS® was developed by the AAMC. It transmits residency applications, letters of recommendation, medical student performance evaluations (MSPE, formerly dean’s letters), transcripts, and other supporting documents to residency program directors via the Internet. ERAS® is also available to IMGs (graduates of medical schools outside the US and Canada) through the ECFMG.
Essential See MUST.
External moonlighting Voluntary, compensated, medically-related work performed outside the institution where the resident is in training or at any of its related participating sites.
Extraordinary Circumstances A circumstance that significantly alters the ability of a sponsor and its programs to support resident education.
Extreme Emergent Situation A local event (such as a hospital-declared disaster for an epidemic) that affect resident education or the work environment but does not rise to the level of an extraordinary circumstance as defined in the ACGME Policies and Procedures, Section 20.00.
Faculty Any individuals who have received a formal assignment to teach resident/fellow physicians. At some sites appointment to the medical staff of the hospital constitutes appointment to the faculty.
Fatigue management Recognition by either a resident or supervisor of a level of resident fatigue that may adversely affect patient safety and enactment of appropriate countermeasures to mitigate the fatigue.
Fellow A physician in a program of graduate medical education accredited by the ACGME who has completed the requirements for eligibility for first board certification in the specialty. The term “subspecialty residents” is also applied to such physicians. Other uses of the term "fellow" require modifiers for precision and clarity, e.g., research fellow.
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Fellowship See SUBSPECIALTY PROGRAM.
Fifth Pathway One of several ways that individuals who obtain their undergraduate medical education abroad can enter GME in the United States. The fifth pathway is a period of supervised clinical training for students who obtained their premedical education in the United States, received undergraduate medical training abroad, and passed Step 1 of the United States Medical Licensing Examination. After these students successfully complete a year of clinical training sponsored by an LCME-accredited US medical school and pass USMLE Step 2, they become eligible for an ACGME-accredited residency as an international medical graduate.
Fitness for duty Mentally and physically able to effectively perform required duties and promote patient safety.
Focused Site Visit A focused site visit assesses selected aspects of a program or sponsoring institution identified by a Review Committee (see ACGME Policies and Procedures, Section 17.30).
Formative Evaluation Assessment of a resident/fellow with the primary purpose of providing feedback for improvement as well as to reinforce skills and behaviors that meet established criteria and standards without passing a judgment in the form of a permanently recorded grade or score.
FREIDA Fellowship Residency Electronic Interactive Database. The Graduate Medical Education Directory (also called the Green Book) and FREIDA Online are resources created by the AMA to assist students in finding a residency program. FREIDA Online is a database with over 7,800 graduate medical education programs accredited by the ACGME as well as over 200 combined specialty programs.
Full Site Visit A full site visit addresses and assesses compliance with all applicable standards and encompasses all aspects of a program or sponsoring institution (see ACGME Policies and Procedures, Section 17.30).
Graduate Medical Education (GME) The period of didactic and clinical education in a medical specialty which follows the completion of a recognized undergraduate medical education and which prepares physicians for the independent practice of medicine in that specialty, also referred to as residency education. The term “graduate medical education’ also applies to the period of didactic and clinical education in a medical subspecialty which follows the completion of education in a recognized medical specialty and which prepares physicians for the independent practice of medicine in that subspecialty.
GME Track GME Track is a resident database and tracking system created in 2000 by the AAMC and the AMA. Its purpose is to assist GME administrators and program directors in the collection and management of GME data.
Graduate Medical Education Committee (GMEC) The Graduate Medical Education Committee shall review from an institutional perspective the implementation at Vanderbilt of the required “Institutional Requirements” of the ACGME. The Committee shall advise and monitor the Office of Graduate Medical Education, the Medical Center, and the Medical School of pertinent issues related to house staff (resident and clinical fellow) programs of the institution. The Sponsoring
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Institution must have a GMEC that has the responsibility for monitoring and advising on all aspects of residency education.
Graduate-Year Level Refers to a resident's current year of accredited GME. This designation may or may not correspond to the resident’s particular year in a program. For example, a resident in pediatric cardiology could be in the first program year of the pediatric cardiology program but in his/her fourth graduate year of GME (including the 3 prior years of pediatrics.) Also referred to as ‘post graduate year’ or ‘PGY”.
Grand Rounds A formal meeting at which physicians discuss the clinical case of one or more patients. Grand rounds originated as part of residency training wherein new information was taught and clinical reasoning skills were enhanced. Grand rounds today are an integral component of medical education. They present clinical problems in medicine by focusing on current or interesting cases.
House Staff Within VUMC GME, House Staff refers to all trainees appointed through the GME Office, including both Residents and Clinical Fellows.
HSAC The Vanderbilt House Staff Advisory Council meets monthly and is composed of representatives from each clinical department. Matters of hospital policy that impact the house staff are discussed and information is disseminated through monthly minutes. Any issue pertaining to house staff experience can be referred to and discussed by the Council.
In-House Call Duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution.
Initial Accreditation A status of “Initial Accreditation” is conferred when a Review Committee determines that an application for a new program or sponsoring institution substantially complies with the requirements. Initial accreditation is considered a developmental stage.
Innovation Experimentation initiated at the program level which may involve an individual program, a group of residents (e.g., PGY1 residents) or an individual resident (e.g., chief resident).
Institutional Review The process undertaken by the ACGME to determine whether a sponsoring institution offering GME programs is in substantial compliance with the Institutional Requirements.
Integrated A site may be considered integrated when the program director a) appoints the members of the faculty and is involved in the appointment of the chief of service at the integrated site, b) determines all rotations and assignments of residents, and c) is responsible for the overall conduct of the educational program in the integrated site. There must be a written agreement between the sponsoring institution and the integrated site stating that these provisions are in effect. This definition does not apply to all specialties. (See specific Program Requirements)
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Intern Historically, a designation for individuals in the first year of GME. This term is no longer used by the ACGME.
Internal Moonlighting Voluntary, compensated, medically-related work (not related with training requirements) performed within the institution in which the resident is in training or at any of its related participating sites.
Internal Review A self-evaluation process undertaken by GMEC to judge whether each program is in substantial compliance with accreditation requirements.
International Medical Graduate (IMG) A graduate from a medical school outside the United States and Canada (and not accredited by the Liaison Committee on Medical Education). IMGs may be citizens of the United States who chose to be educated elsewhere or non-citizens who are admitted to the United States by US Immigration authorities. All IMGs should undertake residency education in the United States before they can obtain a license to practice medicine in the United States even if they were fully educated, licensed, and practicing in another country.
In-Training Examination Formative examinations developed to evaluate resident/fellow progress in meeting the educational objectives of a residency/fellowship program. These examinations may be offered by certification boards or specialty societies.
Joint Commission Joint Commission, formally known as the Joint Commission on Accreditation of Healthcare Organizations or JCAHO, which evaluates and accredits health care organizations in the United States.
LCME Liaison Committee on Medical Education, which accredits programs of medical education leading to the M.D. in the United States and in collaboration with the Committee on Accreditation of Canadian Medical Schools (CACMS), in Canada.
Letter of Notification The official communication from a Review Committee that states the action taken by the Review Committee.
Master Affiliation Agreement A written document that addresses GME responsibilities between a sponsoring institution and a major participating site.
Medical School Affiliation A formal relationship between a medical school and a sponsoring institution.
Milestone A significant point in development. For accreditation purposes, the Milestones are competency-based developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents/fellows from the beginning of their education through graduation to the unsupervised practice of their specialties.
Moonlighting See EXTERNAL MOONLIGHTING and INTERNAL MOONLIGHTING.
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Must A term used to identify a requirement which is mandatory or done without fail. This term indicates an absolute requirement.
National Resident Matching Program (NRMP) A private, not-for-profit corporation established in 1952 to provide a uniform date of appointment to positions in graduate medical education in the United States. Five organizations sponsor the NRMP: American Board of Medical Specialties, American Medical Association, Association of American Medical Colleges, American Hospital Association, and Council of Medical Specialty Societies. It is the most widely used matching program. There are other matches used by some programs such as the San Francisco Match or other specialty matches.
Night Float Rotation or educational experience designed to either eliminate in-house call or to assist other residents during the night. Residents assigned to night float are assigned on-site duty during evening/night shifts and are responsible for admitting or cross-covering patients until morning and do not have daytime assignments. Rotation must have an educational focus.
Notable Practice A process or practice that a Review Committee or other ACGME committee deems worthy of notice. Notable practices are shared through the ACGME web site or other ACGME publications to provide programs and institutions with additional resources for resident education. Notable practices do not create additional requirements for programs or institutions.
One Day Off One (1) continuous 24-hour period free from all administrative, clinical and educational activities.
Ownership of Institution Refers to the governance, control, or type of ownership of the institution.
Pager Call A call taken from outside the assigned site.
PALS Pediatric Advanced Life Support.
PDSA (Plan-Do-Study-Act) A four part method for discovering and correcting assignable causes to improve the quality of processes; the method may be applied to individual learning, courses, programs, institutions, and systems, in repeated cycles.
PLA See PROGRAM LETTER OF AGREEMENT.
Pilot An ACGME-approved project, which is initiated by the Review Committee and involves several residency/fellowship programs that elect to participate.
Preliminary Positions
Designated Positions Positions for residents who have already been accepted into another specialty, but who are completing prerequisites for that specialty (see Program Requirements for Surgery).
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Non-Designated Positions Positions for residents who at the time of admission to a program have not been accepted into any specialty (see Program Requirements for Surgery).
Primary Clinical Site If the sponsoring institution is a hospital, it is by definition the principal or primary teaching hospital for the residency/fellowship program. If the sponsoring institution is a medical school, university, or consortium of hospitals, the hospital that is used most commonly in the residency/fellowship program is recognized as the primary clinical site.
Probationary Accreditation An accreditation status that is conferred when the Review Committee determines that a program or sponsoring institution that has failed to demonstrate substantial compliance with the requirements.
Program A structured educational experience in graduate medical education designed to conform to the Program Requirements of a particular specialty/subspecialty, the satisfactory completion of which may result in eligibility for board certification.
Program Director The one physician designated with authority and accountability for the operation of the residency/fellowship program.
Program Evaluation Systematic collection and analysis of information related to the design, implementation, and outcomes of a resident education program, for the purpose of monitoring and improving the quality and effectiveness of the program.
Progress Report A Review Committee may request a progress report that specifies information to be provided, including a due date for the report. The progress report must be reviewed by the sponsoring institution’s Graduate Medical Education Committee, and must be signed by the designated institutional official prior to submission to the Review Committee.
Program Letter of Agreement (PLA) A written document that addresses GME responsibilities between an individual accredited program and a site other than the sponsoring institution at which residents receive a required part of their education.
Program Merger Two or more programs that combine to create a single program. One program may maintain continued accreditation while accreditation is voluntarily withdrawn from the other program or programs. Alternatively, both programs may be withdrawn and a new program may be established.
Program Year Refers to the current year of education within a specific program; this designation may or may not correspond to the resident’s graduate year level.
Required Educational experiences within a residency/fellowship program designated for completion by all residents/fellows.
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Resident A physician in an accredited graduate medical education program, including interns, residents, and fellows.
Residency A program accredited to provide a structured educational experience designed to conform to the Program Requirements of a particular specialty.
Review Committee Executive Director Appointed by the ACGME Chief Executive Officer, is a chief staff person for a Review Committee and is responsible for all administrative matters of the Review Committee.
Review Committee, Residency Review Committee The function of a Review Committee is to set accreditation standards and to provide a peer evaluation of residency programs and fellowships (or, in the case of the Institutional Review Committee, to set accreditation standards and to provide a peer evaluation of sponsoring institutions).
Rotation An educational experience of planned activities in selected settings, over a specific time period, developed to meet goals and objectives of the program.
Scheduled duty periods Assigned duty within the institution encompassing hours which may be within the normal work day, beyond the normal work day, or a combination of both.
Scholarly Activity An opportunity for residents/fellows and faculty to participate in research, as well as organized clinical discussions, rounds, journal clubs, and conferences. In addition, some members of the faculty should also demonstrate scholarship through one or more of the following: peer-reviewed funding; publication of original research or review articles in peer-reviewed journals or chapters in textbooks; publication or presentation of case reports or clinical series at local, regional, or national professional and scientific society meetings; or participation in national committees or educational organizations. (See Common Program Requirements)
Shall See MUST.
Should A term used to designate requirements so important that their absence must be justified. A program or institution may be cited for failing to comply with a requirement that includes the term ‘should’.
Site An organization providing educational experiences or educational assignments/rotations for residents/fellows.
Major Participating Site A Review Committee-approved site to which all residents in at least one program rotate for a required educational experience, and for which a master affiliation agreement must be in place. To be designated as a major participating site in a two-year program, all residents must spend at least four months in a single required rotation or a combination of required rotations across both years of the program. In programs of three years or longer, all residents must spend at least six months in a single required rotation or a combination of required rotations across all years of the program. The term
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“major participating site” does not apply to sites providing required rotations in one year programs. (see MASTER AFFILIATION AGREEMENT)
Participating Site An organization providing educational experiences or educational assignments/rotations for residents/fellows. Examples of sites include: a university, a medical school, a teaching hospital which includes its ambulatory clinics and related facilities, a private medical practice or group practice, a nursing home, a school of public health, a health department, a federally qualified health center, a public health agency, an organized health care delivery system, a health maintenance organization (HMO), a medical examiner’s office, a consortium or an educational foundation.
Specialty Program A structured educational experience in a field of medical practice following completion of medical school and, in some cases, prerequisite basic clinical education designed to conform to the Program Requirements of a particular specialty; also known as ‘core’ programs.
Sponsoring Institution The organization (or entity) that assumes the ultimate financial and academic responsibility for a program of GME. The sponsoring institution has the primary purpose of providing educational programs and/or health care services (e.g., a university, a medical school, a hospital, a school of public health, a health department, a public health agency, an organized health care delivery system, a medical examiner’s office, a consortium, an educational foundation). [Clarification: When the sponsoring institution is a non-rotation site the major associated hospital is the participating rotation site. Additionally, for multiple ambulatory medical sites under separate ownership from the sponsoring institution one central or corporate site (and address) must represent the satellite clinics (that are located within 10 miles of the main site).]
Strategic napping Short sleep periods, taken as a component of fatigue management, which can mitigate the adverse effects of sleep loss.
Subspecialty Program A structured educational experience following completion of a prerequisite specialty program in GME designed to conform to the Program Requirements of a particular subspecialty.
Dependent Subspecialty Program A program that is required to function in conjunction with an accredited specialty/core program, usually reviewed conjointly with the specialty program, usually sponsored by the same sponsoring institution, and geographically proximate. The continued accreditation of the subspecialty program is dependent on the specialty program maintaining its accreditation.
Suggested A term along with its companion “strongly suggested,” used to indicate that something is distinctly urged rather than required. An institution or program will not be cited for failing to do something that is suggested or strongly suggested.
Summative Evaluation Assessment with the primary purpose of establishing whether or not performance measured at a single defined point in time meets established performance standards, permanently recorded in the form of a grade or score.
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Transfer resident Residents are considered as transfer residents under several conditions including: moving from one program to another within the same or different sponsoring institution; when entering a PGY 2 program requiring a preliminary year even if the resident was simultaneously accepted into the preliminary PGY1 program and the PGY2 program as part of the match (e.g., accepted to both programs right out of medical school). Before accepting a transfer resident, the program director of the ‘receiving program’ must obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation from the current program director. The term ‘transfer resident’ and the responsibilities of the two program directors noted above do not apply to a resident who has successfully completed a residency and then is accepted into a subsequent residency or fellowship program.
Transitional-Year Program A one-year educational experience in GME, which is structured to provide a program of multiple clinical disciplines; its design to facilitate the choice of and/or preparation for a specialty. The transitional year is not a complete graduate education program in preparation for the practice of medicine.
Transitions of care The relaying of complete and accurate patient information between individuals or teams in transferring responsibility for patient care in the healthcare setting.
Unannounced Site Visit A site visit that is unannounced due to the urgency of an issue(s) that needs immediate review. A program may receive up to three weeks’ notice of unannounced site visits.
USMLE United States Medical licensing Exam. USMLE is a three-part exam taken by allopathic medical students and residents. Each part of the USMLE is called a Step. Step 1 is usually taken at the end of the second year of medical school. Step 2 is usually taken prior to graduation from US medical schools. Step 2 has two parts: a clinical knowledge (CK) exam and a clinical skills assessment (CSA or CS). Step 3 is usually taken during or after the first year of residency training.
Warning If a program or sponsoring institution does not demonstrate substantial compliance, a Review Committee may warn a program or sponsoring institution if it determines areas of non-compliance may jeopardize its accreditation status.
Withdrawal of Accreditation A Review Committee determines that a program or sponsoring institution has failed to demonstrate substantial compliance with the requirements.
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Appendix I:
VUMC Graduate Medical Education Records Retention Worksheet for Programs
Program (Educational) File Retention Period Interview Review Sheet(s) Retain for seven (7) years after completion of
program/training
Application (ERAS, Program or Vanderbilt) Retain permanently [does not include letters of recommendation – which should be retained until
completion of program/training]
Family and Contact Information Sheet Retain until completion of program/training
Letter of Offer Retain for up to seven (7) years after completion of
program/end of employment
Visa Information Retain until seven (7) years after completion of
program/training
Reimbursement/Expenses paid by program funds
(travel, meetings, books, etc.)
Retain until completion of program/training
Recognition Letters – awards residents receive
while in training, educational awards
Retain until completion of program/training
Correspondence regarding academic or disciplinary action (except for informal counseling and/or remediation that did not result in corrective action – this is retained only until final
summative evaluation is completed)
Retain permanently [request release of information at time of completion of summative evaluation]
Correspondence/Miscellaneous Retain until completion of program/training
ECFMG (Exchange Commission for Foreign Medical
Graduates) Documentation
Retain permanently
Records of the resident’s/fellow’s rotations,
training experiences, and procedures, as
applicable to the specialty
Retain permanently
In-Training Exam Scores, filed by resident Retain until resident completion of program/training
A summation of the resident’s/fellow’s final summative evaluation, and the letter from the program director indicating readiness for
unsupervised practice
Retain permanently
Recommendation letters – to other
programs/entities/hospitals.
Retain permanently
Employment File/GME File Retention Period Application (ERAS, SOCCA for Critical Care Med., Vanderbilt, San Francisco Match)
Retain permanently [does not include letters of recommendation – which should be retained until
completion of program/training]
Appointment Letter Retain permanently
Current CV Retain permanently
Program Coordinator Manual 86
ECFMG Certificate Retain permanently
ECFMG/CVS reports Retrain permanently
FMLA/LOA documents Retain for seven (7) years after completion of
program/training
House Staff Agreement (contract) Retain for up to seven (7) years after completion of
program/training/end of employment
Letter of request for fellows Retain permanently
Letters of Recommendation (as part of on- boarding, 3 letters of recommendation through ERAS, or if not through ERAS.)
Retain permanently
Loan deferment forms Retain seven (7) years after completion of
program/training
Malpractice Coverage (COC from ORIM) Retain permanently
Medical School Diploma (copy) Retain permanently
Medical School Transcripts (copy) Retain until resident completes program
Misc. documents submitted with required items
(e.g. USMLE, licenses, certifications, awards, etc.)
Retain for seven (7) years after completion of
program/training
Moonlighting forms – all moonlighting including
new innovations
Retain seven (7) years after completion of
program/training/end of employment
Moonlighting Requests Retain until completion of program/training
Name changes Retain permanently
New Hire PAF Retain for seven (7) years after end of
employment/completion of program
NPDB Report Retain permanently
PAF (Payroll Action Form) turnarounds and pay
form copies when available
Retain for seven (7) years after completion of
program/training/end of employment
Prior Training Certificates Retain permanently
Record of disciplinary actions and correspondence Retain permanently
Release Form for Verification Info Retain permanently
Residency Certificate Retain permanently
Resuscitation training (BLS, ACLS, PALS) Retain permanently
Signed House Staff Agreement and Confidentiality
Agreement (annual)
Retain permanently
State License (copy) Retain permanently
State Medical License for Moonlighting Retain permanently
Transcript (including envelope/shipping verification) Retain permanently
Transfer Documentation (letter of request, application, CV, Letters of Recommendation) – in-
bound
Retain permanently
Vacation/Leave Requests Retain until completion of program//training
Visa documents Retain until seven (7) years after completion of program/training/end of employment
VUMC Training Certificates Retain permanently
* If house staff member converts to Faculty or other VUMC employee status, any of above time periods may be extended.
*NOTE THAT IN THE EVENT OF A LITIGATION HOLD/LEGAL PRESERVATION NOTICE, ALL MATERIALS SHOULD BE MAINTAINED UNTIL
NOTICE FROM THE OFFICE OF LEGAL AFFAIRS THAT PRESERVATION IS NO LONGER NECESSARY.